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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600554
Report Date: 07/28/2023
Date Signed: 07/28/2023 04:19:51 PM

Document Has Been Signed on 07/28/2023 04:19 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:A HOME OF OUR OWNFACILITY NUMBER:
015600554
ADMINISTRATOR:FEKETE, EMILYFACILITY TYPE:
740
ADDRESS:2268 MARINA AVENUETELEPHONE:
(925) 443-6218
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY: 6CENSUS: 5DATE:
07/28/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Ildiko Molnar, CaregiverTIME COMPLETED:
04:25 PM
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On 7/28/2023 at 11:00AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct Case Management - Annual Continuation inspection. LPA met with caregiver, Ildiko Molnar. LPA spoke with administrator, Emily Fekete and was informed she was unable to be at the facility during inspection.

During visit, LPA reviewed 5 resident files and 5 staff files starting at 11:30AM. LPA interviewed 2 residents and 2 staff starting at 1:30PM. LPA observed staff completed training which includes dementia, resident rights, hospice, medications, and other topics.

At 2:30PM, LPA reviewed a sample of resident's medications with their centrally stored records and MAR (Medication Administration Records). LPA observed medications were written on the centrally stored records and medications given was recorded on the MAR.

No deficiencies are being cited on this date.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 07/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2023
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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