075601389-2-20-2024-15-AS-AGOZ-D2GTCA-20240215133625

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075601389
Report Date: 02/15/2024
Date Signed: 02/20/2024 03:37:04 PM

Document Has Been Signed on 02/20/2024 03:37 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:	WELCOME HOME SENIOR RESIDENCE (ALAMO)		FACILITY NUMBER:	075601389
ADMINISTRATOR:	CHOU, STEVE & GERONIMO, L.		FACILITY TYPE:	740
ADDRESS:	220 BOLLA AVENUE		TELEPHONE:	(510) 685-8388
CITY:	ALAMO	STATE: CA	ZIP CODE:	94507
CAPACITY:	6	CENSUS: 6	DATE:	02/15/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Lead Care Staff, Marlon Navarro		TIME COMPLETED:	01:50 PM

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Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required visit on this date starting at 9:00am. Upon arrival, LPA met with Lead Care Staff Marlon Navarro and explained the purpose of the visit. Licensee, Steve Chou arrived later at 10:30am. The facility's fire clearance was approved for six non-ambulatory.

LPA toured facility with Caregiver including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of seven (7) total bedrooms which six (6) are occupied by the residents and one (1) is occupied by staff. 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 are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 106.7 degrees F. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps are locked and inaccessible to residents.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 11/14/2023. Emergency Disaster Plan is posted. First aid kit was observed to be complete. Fire drill was last conducted on 12/12/2023.

LPA reviewed 4 staff records and 3 of 4 staff have current first aid training and associated to the facility. LPA reviewed 5 residents records and 5 of 5 residents have current medical assessment.

Report continues on 809C

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: WELCOME HOME SENIOR RESIDENCE (ALAMO)	FACILITY NUMBER: 075601389
	VISIT DATE: 02/15/2024

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Updated copies of the following documents were requested for facility file and are to be submitted to CCLD by 2/29/2024:

· Resident Roster

· LIC 308 Designation of Administrative Responsibility

· LIC 500 Personnel Report

· LIC 610E Emergency Disaster Plan (9 pages)

· Liability Insurance

No deficiencies cited during visit.

Exit interview conducted with Licensee. A copy of this report provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

LIC809 (FAS) - (06/04)

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