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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275202839
Report Date: 12/22/2021
Date Signed: 12/23/2021 08:37:51 AM

Document Has Been Signed on 12/23/2021 08:37 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, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:HARTNELL HOME ONEFACILITY NUMBER:
275202839
ADMINISTRATOR:TEODORO, ALVIN PATRICKFACILITY TYPE:
735
ADDRESS:618 HARTNELL ST.TELEPHONE:
(415) 336-5277
CITY:SALINASSTATE: CAZIP CODE:
93901
CAPACITY: 6CENSUS: 4DATE:
12/22/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
04:05 PM
MET WITH:Patrick Binarao & Alvin TeodoroTIME COMPLETED:
05:37 PM
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Licensing Program Analyst (LPA) Ryker Heberle conducted an unannounced pre-licensing inspection on 12/22/2021 at 4:05pm. LPA met with Administrator Patrick Binarao (ADM) and Licensee Alvin Teodoro (LC).

At around 04:05pm, LPA toured the facility inside and out. Including living room, kitchen, 2 staff rooms, 3 resident rooms, 3 bathrooms, garage, and backyard.

The facility is equipped with connected smoke detectors. The smoke detector located in the living room by the hallway was tested and observed working. All fire/carbon monoxide detectors observed to be connected. Fire extinguisher was observed in the kitchen which had tags indicating service in June 2021. The kitchen, dining, and living room were observed in good repair. Resident and personnel files observed to contain all necessary documentation.

Resident bedrooms were observed in good repair, furnished, with clean linens and adequate lighting. Bathrooms were observed clean and equipped with grab bars and non-skid mats. The water temperature in the bathroom was measured at 116.1 degrees F. Centrally stored medication cabinet, and a cabinet with non-perishable and emergency food supplies was observed. A complete first aid kit was inspected. The backyard was inspected. All outdoor and indoor passageways were observed clear and free of obstruction. No bodies of water observed.

Component III orientation was waived due to ADM's and LC's prior experience. No deficiencies cited. No issues noted during the pre-licensing inspection. The physical plant is approved pending the completion of Centralized Application Bureau (CAB) review of the facility application. Due to issues with printer, LPA sent this report to LC via email. Exit interview was conducted and a copy of this report was provided to Licensee Alvin Teodoro.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Ryker Heberle
LICENSING EVALUATOR SIGNATURE: DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/22/2021
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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