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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601315
Report Date: 08/19/2022
Date Signed: 08/19/2022 04:21:23 PM

Document Has Been Signed on 08/19/2022 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:ISHERWOOD CARE IIIFACILITY NUMBER:
015601315
ADMINISTRATOR:CAYABYAB, LAURO & ZORAIDAFACILITY TYPE:
740
ADDRESS:1445 SKELTON AVENUETELEPHONE:
(510) 894-4571
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY: 6CENSUS: 5DATE:
08/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Licensee- Lauro CayabyabTIME COMPLETED:
04:30 PM
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On today’s date, at 3:20 PM, Licensing Program Analysts (LPAs) L. Fici and C. Lin arrived unannounced to conduct an Annual Infection Control Visit. LPAs was greeted by licensee at front door entrance.

During the inspection, LPAs toured facility with licensee including but not limited to front entrance, kitchen, common areas, hand washing stations, bedrooms, bathrooms, and backyard. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. All sharps and toxins were locked up and inaccessible to clients in care. Common areas are disinfected frequently throughout the day. Water temperature is measured at 119.2. Fire extinguisher was last serviced on 8/25/2021. Carbon monoxide and smoke detector are operable. Facility passages inside and out are free of obstruction and does not pose a health and safety risk for persons in care.

During record review, LPAs observed facility has a copy of their Infection Control Plan on file.

No deficiencies cited during visit.

Exit interview conducted with licensee and copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2022
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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