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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200830
Report Date: 02/24/2023
Date Signed: 02/24/2023 10:06:04 AM

Document Has Been Signed on 02/24/2023 10:06 AM - 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:FAIRBANKS ONEFACILITY NUMBER:
019200830
ADMINISTRATOR:MONCEA, VIORICAFACILITY TYPE:
740
ADDRESS:2946 SOMERSET AVETELEPHONE:
(510) 586-0909
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94546
CAPACITY: 6CENSUS: 5DATE:
02/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Viorica V Moncea, AdministratorTIME COMPLETED:
10:15 AM
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On 2/24/23 at 9:00AM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct Infection Control Inspection. LPA met with Administrator, Viorica Moncea and explained the purpose of the visit.

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. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Facility staff were observed to be wearing proper PPE.

During record review, LPAs reviewed a sample of 3 staff records and observed 3 of 3 have health screening with TB test on file.

Report Continue on LIC 809C...

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: FAIRBANKS ONE
FACILITY NUMBER: 019200830
VISIT DATE: 02/24/2023
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Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 03/03/2023:

LIC 308 Designation of Administrative Responsibility

LIC 309 Administrative Organization

LIC 500 Personnel Report

LIC 610E Emergency Disaster Plan

Liability Insurance

Current Administrator’s Certificate

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023
LIC809 (FAS) - (06/04)
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