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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801008
Report Date: 08/17/2021
Date Signed: 08/17/2021 04:42:09 PM

Document Has Been Signed on 08/17/2021 04:42 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:ALAMEDA HOUSEFACILITY NUMBER:
425801008
ADMINISTRATOR:NICHOLAS PAPAGEORGEFACILITY TYPE:
735
ADDRESS:7167 ALAMEDA AVENUETELEPHONE:
(805) 685-1111
CITY:GOLETASTATE: CAZIP CODE:
93117
CAPACITY: 6CENSUS: 5DATE:
08/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Administrator Jennifer GoddardTIME COMPLETED:
03:40 PM
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On 8/17/21 at 01:40 PM, Licensing Program Analyst (LPA) Toan Luong contacted Administrator Nick Papageorge to perform a facility risk assessment. LPA conducted an unannounced on-site One Year Infectious Control Annual visit to the facility. LPA met with Administrator Jennifer Goddard. LPA explained the purpose of the visit.

Administrator took LPA on a physical plant tour of the facility. The facility has submitted a mitigation plan to the department.

The facility is an Adult Residential Facility. During the facility tour, LPA advised Administrator to post signs at entrance of Covid-19 guidance. LPA advise Administrator to have CDSS PINs posted and readily accessible to clients, visitors, and staff. LPA recommended facility include space to include contact information for visitor sign-in sheet. LPA discussed with Administrator about having staff be fit-tested for N95 respirators.

LPA reviewed the Annual Mitigation Inspection Control Tool Module. Module was addressed with Administrator to satisfaction.

Exit interview was conducted. No deficiencies were cited. Report was emailed to Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Toan Luong
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2021
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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