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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600491
Report Date: 06/17/2021
Date Signed: 06/17/2021 03:24:43 PM

Document Has Been Signed on 06/17/2021 03:24 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:YOUNG IN HEART II, THEFACILITY NUMBER:
075600491
ADMINISTRATOR:CICAI, A.& D.FACILITY TYPE:
740
ADDRESS:4060 SIINO AVENUETELEPHONE:
(925) 825-7460
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY: 6CENSUS: 4DATE:
06/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Aurora CicaiTIME COMPLETED:
03:45 PM
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On 6/17/2021 at 1:15PM Licensing Program Analyst (LPA) Leslie Ibo arrived unannounced to conduct an annual required inspection. LPA met with Administrator Aurora CIcai. LPA to informed Administrator the purpose of visit. Facility has census of 4.

LPA toured the facility inside and out including but not limited to common areas, resident rooms, bathrooms, kitchen patio and backyard. Facility has enough supplies of paper supplies and hygiene supplies. Medications are centrally stored in a locked area that is inaccessible to clients and refilled every at least 30 days.
Facility has enough 2-day perishable food and one-week non-perishable food supply. Visitors policy is posted on the front entrance. There is one central entry point for universal screening for staff, residents and visitors. A 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. Facility has a mitigation plan.
LPA observed the following:
NO gowns available during the visit – Administrator ordered supplies delivery date between 2-4 days
FIT testing was not completed for all employees - Administrator will arrange another FIT testing schedule for the rest of the staffs, schedule document will be sent to LPA.
Visitor sign in log was incomplete – Administrator will create a visitor log that reflects covid19 guidelines .
Temperature & Covid19 screening questions was not implemented for staff and residents– Administrator will create a log for temperature & covid19 screening for staffs and residents.

No deficiency cited during the visit.
Exit interview conducted. Appeal Rights and copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 06/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2021
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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