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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600176
Report Date: 07/27/2023
Date Signed: 07/27/2023 03:44:47 PM


Document Has Been Signed on 07/27/2023 03:44 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:HAILEY'S CARE HOMEFACILITY NUMBER:
075600176
ADMINISTRATOR:RIFORMO, MARIAFACILITY TYPE:
740
ADDRESS:3831 LA COLINA ROADTELEPHONE:
(510) 222-0945
CITY:EL SOBRANTESTATE: CAZIP CODE:
94803
CAPACITY:6CENSUS: 0DATE:
07/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Matthew Riformo, Administrator ADMTIME COMPLETED:
04:00 PM
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On 07/27/23 around 01:10 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct a required annual inspection. LPA contacted Maria Riformo (ADM) and explained the purpose of the visit. Matthew Riformo, Administrator (ADM) arrived about 10 minutes later to assist with the inspection. ADM currently holds a standard certificate (#6045022740). The facility’s fire clearance was approved for six (6), no more than four (4) non-ambulatory residents and one (1) bedridden.

Upon entry, LPA and ADM toured the facility including, but not limited to common areas, bathroom, bedrooms, kitchen, and backyard. LPA observed mask, cough etiquette, social distancing and hand washing signs posted throughout. The facility has an updated Infection Control Plan (ICP). All hand washing stations were equipped with soap, paper towels and covered garbage cans. There is a surplus of PPE centrally located inside the facility that is accessible to all care staff. Hot water temperature in the shared residents' bathroom was measured at 106.5 degrees Fahrenheit (F) and the facility's temperature was comfortable. Fire extinguisher was observed full. Smoke/Carbon Monoxide detectors were observed operational and first aid kit complete.

continued on LIC809C...
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2023
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 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: HAILEY'S CARE HOME
FACILITY NUMBER: 075600176
VISIT DATE: 07/27/2023
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...continued from LIC809.

LPA reviewed two (2) complete staff records. There are not any residents at this time.

The following forms are to be updated and submitted to CCLD:
-LIC500 Personnel Report (Reviewed)
-LIC308 Designation of Administrative Responsibility (Reviewed)
-LIC610E Emergency Disaster Plan (Reviewed)
-An updated copy of Administrator Certificate(s)

Exit interview conducted and a copy of this report provided to ADM.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023
LIC809 (FAS) - (06/04)
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