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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200693
Report Date: 03/11/2022
Date Signed: 03/11/2022 04:26:20 PM

Document Has Been Signed on 03/11/2022 04:26 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-N-D CARE HOMESFACILITY NUMBER:
019200693
ADMINISTRATOR:HAMZA, MORENIKEFACILITY TYPE:
740
ADDRESS:3284 COURTHOUSE PLACETELEPHONE:
(510) 574-9305
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 3CENSUS: 1DATE:
03/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Morenike Hamza, AdministratorTIME COMPLETED:
04:35 PM
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On 3/11/2022 at 3:10 PM, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to conduct Infection Control Inspection. LPA met with Administrator, Morenike Hamza and explained the purpose of the visit.

Facility is a two level house. First level is the licensed part and second level serves as residence of Administrator and her family. During the Infection Control Inspection, LPA toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and backyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. There is one central entry point for universal screening for staff, residents and visitors. Facility has a mitigation plan.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Lizette Francisco
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2022
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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