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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200392
Report Date: 11/21/2022
Date Signed: 11/21/2022 02:43:05 PM

Document Has Been Signed on 11/21/2022 02:43 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:EMA BOARD AND CAREHOMEFACILITY NUMBER:
079200392
ADMINISTRATOR:EDWIN LIWANAGFACILITY TYPE:
740
ADDRESS:1131 ALAMO WAYTELEPHONE:
(925) 458-7098
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY: 10CENSUS: 6DATE:
11/21/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Merla Fernandez, CaregiverTIME COMPLETED:
02:50 PM
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On 11/21/2022, at 1:00PM, Licensing Program Analysts (LPAs) L. Hall and L. Holmes arrived unannounced to conduct proof of correction (POC) visit. LPA met with Merla Fernandez, Caregiver and explained the purpose of the visit. LPA spoke with Administrator, Edwin Liwanag and was given approval for Caregiver to sign documents.

Facility has the following deficiencies that were not cleared:

  • 87555(b)(32), LPA has not received picture of operable refrigerator in kitchen after annual inspection visit 11/3/2022 and POC date 11/10/2022.
  • 87411(c)(1), LPA have not received updated first aid certificate for S2, after annual inspection visit 11/3/2022 and POC date 11/10/2022.

Civil Penalties for 87555(b)(32) in the amount of $1,100 assessed immediately for the period of 11/11/2022 - 11/21/2022.
Civil Penalties for 87411(c)(1) in the amount of $1,100 assessed immediately for the period of 11/11/2022 - 11/21/2022.

Civil Penalties in the total amount of $2,200 is assessed today for failure to meet POC date for deficiencies. Facility is subject to ongoing civil penalties until deficiency is corrected.

Exit interview conducted. A copy of this report, appeal rights provided and LIC421FC provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2022
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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