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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200693
Report Date: 08/22/2023
Date Signed: 08/22/2023 03:18:15 PM

Document Has Been Signed on 08/22/2023 03:18 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
OAKLAND ASC, 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: 3DATE:
08/22/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Morenike HamzaTIME COMPLETED:
03:15 PM
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On 08/22/2023 at 10:30 AM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to conduct the initial 10-day complaint investigation. Upon entry, LPA informed Ade Hamza who informed Administrator (ADM) Morenike Hamza of the purpose of the visit.

During the investigation, the LPA observed that the ADM was dispensing medications in a manner not consistent with Title 22. Because the manner of dispensing medications did not pose a health, safety, or personal rights risk, an advisory note (LIC9102) was issued.

Exit interview was conducted with ADM. A copy of this report was provided via email.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2023
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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