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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700915
Report Date: 11/18/2020
Date Signed: 11/18/2020 04:44:48 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:ROBUST CARE HOME, LLCFACILITY NUMBER:
392700915
ADMINISTRATOR:UBALDO, YASHMINFACILITY TYPE:
740
ADDRESS:1627 MERIDIAN STREETTELEPHONE:
(650) 653-1608
CITY:MANTECASTATE: CAZIP CODE:
95337
CAPACITY:4CENSUS: 0DATE:
11/18/2020
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Yashmin Ubaldo, AdministratorTIME COMPLETED:
09:25 AM
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LPA Bruce Jacobs conducted a televisit with applicant Yashmin Ubaldo to conduct a Component III and Pre-Licensing inspection. This facility is intending to be vendorized home with Valley Mountain Regional Center for a Level 4I home. This facility received fire clearance for 4 non-ambulatory residents on 10/12/20.

LPAs toured the facility inside and out visually. The inside of the facility was observed to be in good condition and repair. LPA observed a breakfast table in the kitchen with chairs. Plates and utensils were observed to be in place. Dishwasher, stove, refrigerator, and microwave all present and working. The facility has a fully charged fire extinguisher that was serviced in April 2020 and functioning smoke alarms and all exit doors have sound alarms. Smoke detectors were tested are operable. The home has a carbon monoxide detector and built in sprinkler system. Hot water measured at 112 degrees. Home has a first aid kit

4 client bedrooms were observed. Bathrooms were observed to be in good repair and had grab bars. Adequate linens such as sheets, blankets, etc. were observed. Storage and lighting was adequate in the home. Medications are to be locked up in a small medication cabinet. Washer and dryer observed in place..Component III was conducted

The facility has separate locked storage area for toxins, hazardous items, medication and records. Then this prelicensing inspection report will be sent to the applications unit.

The applicant was advised this report would be sent to the applications unit.

Exit interview and copy of report provided via email for signature.
SUPERVISOR'S NAME: Krystall MooreTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Bruce JacobsTELEPHONE: (916) 956-5861
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2020
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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