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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200694
Report Date: 12/12/2024
Date Signed: 12/12/2024 02:37:37 PM

Document Has Been Signed on 12/12/2024 02:37 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:H & M HOMES STANDISHFACILITY NUMBER:
019200694
ADMINISTRATOR/
DIRECTOR:		OLIVE LOPEZFACILITY TYPE:
740
ADDRESS:18543 STANDISH AVENUETELEPHONE:
(510) 276-2240
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 6CENSUS: 6DATE:
12/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Administrator, Olive Lyn NeriTIME VISIT/
INSPECTION COMPLETED:
02:55 PM
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On 12/12/2024 at 12:20 pm, Licensing Program Analyst (LPA) Ardalan Gharachorloo arrived unannounced to conduct 1-Year Annual Required inspection. At 12:57 pm, LPA met with Administrator,Olive Lyn L Neri and explained the purpose of the visit.

LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 76 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 109 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of non-perishable and 2 day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents.

Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 07/15/2024. Emergency Disaster Plan was last posted on 3/5/2024. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 11/19/2024.

At 1:15 pm, LPA reviewed 6 residents records and 5 staff records; all were complete. At 1:45 pm, LPA also reviewed 6 residents medications. At 2:05 pm the following the documents were requested and reviewed:LIC 308 Designation of Administrative Responsibility,LIC 309 Administrative Organization ,LIC 500 Personnel Report, LIC 610E Emergency Disaster Plan, Liability Insurance, and Current Administrator’s Certificate

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Ardalan Gharachorloo
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2024
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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