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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200581
Report Date: 03/19/2024
Date Signed: 03/19/2024 02:08:33 PM


Document Has Been Signed on 03/19/2024 02:08 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:POET'S VISTA RESIDENTIAL CAREFACILITY NUMBER:
079200581
ADMINISTRATOR:BATHA, HAIMANOTFACILITY TYPE:
740
ADDRESS:204 ROBERTA AVENUETELEPHONE:
(510) 318-2906
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY:6CENSUS: 3DATE:
03/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Haimanot Batha, AdministratorTIME COMPLETED:
02:20 PM
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On 03/19/2024 at 10:45 AM, Licensing Program Analyst (LPA) Lori Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Caregiver, Lidya Hailu and explained the purpose of the visit. Lidya phoned Administrator, Haimanot Bahta, to inform. Administrator, Haimanot arrived approx. 11:50 AM. The facility’s fire clearance was approved for capacity of 6 (Six) residents in which 1 (One) can be Bedridden. Hospice waiver approved for 2 (Two) residents. Administrator Certificate #6040140740 Expires 05/18/2024.

LPA toured facility with Haimanot including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 7 total bedrooms which 6 bedrooms are occupied by the residents and 1 bedroom 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 70 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 108.3 degrees Fahrenheit. 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 were locked and inaccessible to residents.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2024
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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: POET'S VISTA RESIDENTIAL CARE
FACILITY NUMBER: 079200581
VISIT DATE: 03/19/2024
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Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 01/25/2024. Emergency Disaster Plan was last posted on 03/19/2024. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 01/25/2024.

LPA reviewed 3 residents records. LPA reviewed 6 staff records and 6 of 6 have current first aid training and associated to the facility.


Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 03/26/2024:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report - Reviewed
Liability Insurance
Current Administrator’s Certificate - Reviewed

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024
LIC809 (FAS) - (06/04)
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