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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700918
Report Date: 01/12/2021
Date Signed: 01/12/2021 06:29:40 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:KIERNAN VILLE MANORFACILITY NUMBER:
502700918
ADMINISTRATOR:CRUZ, EVELYN SANCHEZFACILITY TYPE:
740
ADDRESS:5412 KIERNAN AVENUETELEPHONE:
(510) 825-6614
CITY:SALIDASTATE: CAZIP CODE:
95368
CAPACITY:32CENSUS: 0DATE:
01/12/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:evelyn cruzTIME COMPLETED:
11:44 AM
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Announced Pre-licensing visit was made by LPA Eric Stone via Facetime on 1/12/2021 with Administrator Evleyn Cruz.

The facility will be licensed to serve up to 32 residents at any given time. There were no residents in care during today's Pre-licensing visit.

Tour of the facility was conducted via Facetime. The facility has one floor with 16 rooms. all for memory care, non-ambulatory and Hospice. There is one dining areas, 2 large activity areas and 1 medication rooms, and 1 living room. The facility also has a laundry room and 2 janitorial rooms.

A tour via Facetime was conducted of the memory care facility. Observed were the 2 different type of bedrooms for residents, kitchen area, dining areas, laundry room and janitorial room were viewed and are in compliance at this time.

The Facility has 1 Medication room that is locked and secured along with the first aid kits. Medication room contained all required components at this time. The facility has 3 fire extinguishers (EXP-12/11/21) placed throughout the facility.

There were no deficiencies observed during today's Pre-licensing visit.
LPA Stone completed Component 111 requirements with the facility.

Report will be emailed for signature and emailed back to LPA Stone
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Eric StoneTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2021
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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