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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601459
Report Date: 04/09/2024
Date Signed: 04/09/2024 04:21:15 PM


Document Has Been Signed on 04/09/2024 04:21 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:BALTIC SEA MANORFACILITY NUMBER:
075601459
ADMINISTRATOR:PRICE, VIVIANFACILITY TYPE:
740
ADDRESS:311 BALTIC SEA COURTTELEPHONE:
(925) 783-0988
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY:6CENSUS: 5DATE:
04/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Florin Jervoso, CaregiverTIME COMPLETED:
04:30 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
On 4/09/2023 at 2:45pm, Licensing Program Analyst (LPA) L. Hall conducted an unannounced 1-Year Required inspection. LPA met with Caregiver, Florin Jervoso and explained the purpose of the visit. The Administrator, Vivian Price, arrived at 3:20pm. The Administrator currently holds a certificate (#6017788740) that expires on 06/19/2024. The facility’s fire clearance was approved for five (5) non-ambulatory and 1 bedridden resident.

LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of four (4) bedrooms and two (2) bathrooms. One (1) bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. A comfortable temperature is maintained at 71 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 103.5 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods.

Smoke detectors/ carbon monoxide were in operating condition during visit. Fire extinguisher was last purchased on 04/26/2023. Emergency Disaster Plan was last posted on 5/16/2022. First aid kit was observed to be complete. Fire drill was last conducted on 01/15/2024.

Continued on LIC809.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2024
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 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: BALTIC SEA MANOR
FACILITY NUMBER: 075601459
VISIT DATE: 04/09/2024
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
26
27
28
29
30
31
32
Continued from LIC809.

Three (3) staff records were reviewed, complete and current. All five (5) Client records were reviewed.

LPA requested the following documents to be submitted to CCLD by 4/16/2023.
  • LIC 308 Designation of Administrative Responsibility
  • LIC 309 Administrative Organization
  • LIC 500 Personnel Report
  • LIC 610E Emergency Disaster Plan
  • Liability Insurance


Exit interview conducted and a copy of this report provided.


SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2