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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803943
Report Date: 02/27/2023
Date Signed: 02/27/2023 11:53:10 AM


Document Has Been Signed on 02/27/2023 11:53 AM - 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:ALAMEDA HOMEFACILITY NUMBER:
216803943
ADMINISTRATOR:LIU, FANGFACILITY TYPE:
735
ADDRESS:405 ALAMEDA DE LA LOMATELEPHONE:
(415) 516-3162
CITY:NOVATOSTATE: CAZIP CODE:
94949
CAPACITY:4CENSUS: 2DATE:
02/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator/Licensee Annie (Fang) LiuTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Jill Nakagawa conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with administrator/Licensee Annie (Fang) Liu There were (2) clients and (1) staff present and (1) staff on call at the facility. One of the clients was participating in an activity at the time of inspection.
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LPA found the facility to be clean and at a comfortable temperature with all exits free from obstruction. Clients' bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 04/25/2022 and fully charged at the time of the visit. Carbon monoxide detector and smoke detectors test was conducted and were operational during this visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator was properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked closet in the hallway. Dangerous items were stored inaccessible to clients. There was a supply of cleaners, hygiene products and paper products available for clients. Clients' bedrooms had lighting & appropriate furnishings; mattress pads are available for clients at the facility. Facility hot water temperature in faucets measured between 111 and 112 degrees F in 2 out of 2 faucets within Title 22 acceptable regulations of 105 to 120 degrees F.

Facility has submitted a mitigation program plan that has been approved. Posters have been placed at facility, container with hand sanitizer and other items designated for visitors are at entrance. Staff has temperature checked before work. Facility has PPE supply stored in the garage/staff office area. Clients’ medications are stored and locked in medication cabinet in kitchen area. Facility has a 30-day supply of medication for clients.

Department is requesting Licensee to update the following documents and submit to CCL by 03/03/2023:
LIC 500 Personnel Summary
LIC 402 Surety Bond (if applicable)
LIC 9020 Register of Facility Clients/Residents

No deficiencies found at the time of inspection. No citations issued.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2023
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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