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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700915
Report Date: 11/28/2022
Date Signed: 12/01/2022 12:00:43 PM


Document Has Been Signed on 12/01/2022 12:00 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, 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: 2DATE:
11/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Yashmin UbaldoTIME COMPLETED:
04:30 PM
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Unannounced annual visit made out to this facility on 11/28/2022 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Yashmin Ubaldo, who was briefly interviewed at this time.
This facility is additionally vendorized through Valley Mountain Regional Center to accept and retain up to (4) residents at Level 4I.
Current census was (2) residents.
Tour of this facility was conducted.
Living room, dining room, and all other areas designated for resident use were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Kitchen area was toured. Cabinets and drawers containing items and materials for use by the residents were reviewed. Storage spaces housing knives and chemicals were observed to be locked and made inaccessible to the residents at this time.
Food supply for 2-day perishable and 7-day nonperishable quantities were observed to be present and able to meet the needs of the residents at this time.
Medication cabinet, located in the kitchen area, was observed to be locked and made inaccessible to the residents at this time. Policies and procedures for handling, dispensing, and documenting of all resident medications were discussed with the facility designated Administrator at this time.
First aid kit was observed to be present and did contain all of the required components at this time.
A tour of the resident bedrooms was conducted. Bedroom furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
A tour of the resident restrooms was conducted. Grab bars and non skid mats/surfaces were observed to present and in functional order at this time. Linen closet was observed to be present in a resident restroom and did contain all of the necessary towels and wash cloths to meet the needs of the residents.
Hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees at all times.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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, LLC
FACILITY NUMBER: 392700915
VISIT DATE: 11/28/2022
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Laundry area was toured. It was learned that all laundry detergent, bleach, and cleaning agents were stored in the garage area at this time.
Garage area was toured. All cleaning agents, supplies, and laundry chemicals were observed to be locked and made inaccessible to the residents at this time.
Additional nonperishable food supplies were observed to be present in the garage area at this time.
Fire extinguishers were observed to be present and placed throughout this facility. They were observed to have been annually inspected by the local fire extinguisher company, Armor Fire Extinguisher Company, on 07/12/2022 and in compliance at this time.
A tour of the facility exterior grounds was conducted. A review of the facility perimeter fence, side gate, and exits was conducted.

The following forms and documents were requested by this LPA to be updated and submitted into CCL for review by this LPA:

LIC 308

LIC 400

LIC 500

LIC 610

There were no deficiencies observed or cited during today's annual visit.

Exit Interview
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:

DATE: 11/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2022
LIC809 (FAS) - (06/04)
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