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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200896
Report Date: 08/12/2024
Date Signed: 08/12/2024 01:05:23 PM


Document Has Been Signed on 08/12/2024 01:05 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:CASA SAN LORENZOFACILITY NUMBER:
019200896
ADMINISTRATOR:HOSAIN, MARIA LUISAFACILITY TYPE:
740
ADDRESS:171 VIA LINARESTELEPHONE:
(510) 329-9300
CITY:SAN LORENZOSTATE: CAZIP CODE:
94580
CAPACITY:6CENSUS: 4DATE:
08/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Maria Luisa Hosain, AdministratorTIME COMPLETED:
01:30 PM
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On 8/12/2024 at 10:20am, Licensing Program Analysts (LPAs) K. Nguyen and D. Doidge conducted an unannounced 1-Year Required inspection. LPAs met with administrator (AD) Maria Luisa Hosain, and explained the purpose of the visit. The Administrator currently holds a certificate (#6010517740) that expires on 02/10/2024. AD already renew her certificate and waiting for her new certificate to arrive. The facility’s fire clearance was approved for six (6) non-ambulatory residents. Fire drill was conducted on 4/8/24. Facility has a current liability insurance 11/4/23 to 11/4/24.

LPAs toured the facility with Caregiver including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard. The facility consists of five (5) total bedrooms which one (1) bedroom is occupied by staff. No bodies of water observed. A comfortable temperature is maintained at 69 degrees Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 120.0 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 11/6/2023. First aid kit was observed to be complete.

LPAs reviewed four (4) of four residents files and four (4) of four (4) staff files, which were all complete. LPAs reviewed three staff files. 3 out of 3 are fingerprint cleared and associated to the facility.

No deficiency cited during visit. Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 08/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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