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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601535
Report Date: 07/22/2021
Date Signed: 07/22/2021 11:56:17 AM

Document Has Been Signed on 07/22/2021 11:56 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:CARTER PLACEFACILITY NUMBER:
075601535
ADMINISTRATOR:SALINAS, TOMASFACILITY TYPE:
740
ADDRESS:27 CARTER CT.TELEPHONE:
(510) 223-1696
CITY:EL SOBRANTESTATE: CAZIP CODE:
94803
CAPACITY: 6CENSUS: 5DATE:
07/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Tomas SalinasTIME COMPLETED:
12:15 PM
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On 7/22/2021 at 9:50 AM, Licensing Program Analyst (LPA) Leslie Ibo conducted an infection control annual inspection and explained the purpose of the visit with Administrator Tomas Salinas . LPA observed 1 resident relaxing outdoor area while the other 4 residents were resting in their bedrooms.

LPA inspected the facility inside and outside. LPA observed no bodies of water. Pathways were observed to be free of obstruction and fire hazards.

Infection control designated leader is the Administrator. LPA observed COVID-19 posters posted in common areas to promote hand washing, cough/sneeze etiquette and physical distancing. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Facility staff were observed to be wearing proper PPE (mask). Facility has a mitigation plan and maintains record of routine screening for residents and staff. Facility has enough supplies of PPEs, 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. There was at least 7 days of nonperishable and 2 days of perishable foods. Hot water temperature was measured at 112.2 degrees Fahrenheit . A certified administrator is on site a minimum of 20 hours a week to oversee proper business operation. Smoke and Carbon monoxide detectors were operational.

LPA observed:
Facility has NOT conducted staff training on infection prevention, symptoms, transmission and PPE use (technical assistance was provided).

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: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2021
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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