<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 071441125
Report Date: 01/18/2024
Date Signed: 01/18/2024 12:06:09 PM


Document Has Been Signed on 01/18/2024 12:06 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:CASA BLANCA RETIREMENT HOMESFACILITY NUMBER:
071441125
ADMINISTRATOR:SHEILA V MELECIONFACILITY TYPE:
740
ADDRESS:1055 INA DRIVETELEPHONE:
(925) 838-2523
CITY:ALAMOSTATE: CAZIP CODE:
94507
CAPACITY:18CENSUS: 11DATE:
01/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Sheila MelencionTIME COMPLETED:
12:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) A. Gomez conducted an unannounced 1-year Required visit on this date. LPA met and toured with Administrator, Sheila Melencion. The Administrator currently holds a certificate (#602427740) that expires on 5/11/2025. The facility’s fire clearance was approved for a capacity of 18 which 16 may be non-ambulatory and subject to five (5) hospice waivers.

LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 72 degrees Fahrenheit. LPA observed lighting in all rooms that are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 107.9 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of 2-day of perishable foods and a minimum 7-day non-perishable foods.

Smoke detectors and carbon monoxide were in operating condition during visit. LPA observed sprinklers throughout the facility. Fire extinguisher was last serviced on 1/09/2024. Fire Drill was last conducted on 01/10/2024. First aid kit was observed to be complete.

LPA reviewed 3 staff records and staff have criminal record clearance and are associated to the facility. 3 of 3 have current first aid training. LPA reviewed 4 residents’ records and a sample of medication.

No Deficiencies cited. Exit interview conducted and a copy of this report provided

SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1