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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601535
Report Date: 07/19/2024
Date Signed: 07/19/2024 10:37:52 AM


Document Has Been Signed on 07/19/2024 10:37 AM - 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:CARTER PLACEFACILITY NUMBER:
075601535
ADMINISTRATOR:SALINAS, TOMASFACILITY TYPE:
740
ADDRESS:27 CARTER CT.TELEPHONE:
(510) 223-1696
CITY:EL SOBRANTESTATE: CAZIP CODE:
94803
CAPACITY:6CENSUS: 6DATE:
07/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Tomas Salinas, Administrator (ADM) TIME COMPLETED:
11:00 AM
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On 07/19/24 around 08:30 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct a required annual inspection. LPA was greeted by one staff upon entry and explained the purpose of the visit. Tomas Salinas, Administrator (ADM) arrived shortly after. ADM currently holds a standard certificate (#6023774740). The facility’s fire clearance was approved for six (6) non-ambulatory residents; one (1) may be bedridden and hospice waiver for three (3).

Upon entry, LPA observed two residents eating breakfast and the other watching television. LPA and ADM toured the facility including, but not limited to common areas, bathrooms, bedrooms, kitchen, storage area, and backyard. LPA observed mask, cough etiquette, social distancing and hand washing signs posted throughout. There was a sufficient supply of 2-day perishables and 7-day supply of non-perishable foods. All hand washing stations were equipped with soap, paper towels and garbage cans. There is a surplus of PPE stored in the downstairs area and centrally located inside the facility that is accessible to all care staff. Hot water temperature in the shared residents' bathroom was measured at 107.1 degrees Fahrenheit (F) and the facility's temperature was very comfortable at 73 degrees (F). Fire extinguisher was observed full and last serviced 07/10/24. 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: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2024
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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: CARTER PLACE
FACILITY NUMBER: 075601535
VISIT DATE: 07/19/2024
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Document Link Icon..continued from LIC809.

Emergency Disaster Plan is current. Safety drills were last conducted 06/2024 and are rotational between AM and PM schedules monthly.

LPA reviewed three (3) staff records, two (2) were complete, and five (5) completed resident records. ADM to complete personnel file; standard certificate is still pending.

The following forms are to be updated and submitted to CCLD 07/26/24:
-LIC500 Personnel Report
-LIC308 Designation of Administrative Responsibility (Reviewed)
-LIC610E Emergency Disaster Plan (Reviewed)
-An updated copy of Administrator Certificate (Status)

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: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024
LIC809 (FAS) - (06/04)
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