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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200781
Report Date: 12/02/2021
Date Signed: 12/02/2021 10:16:22 AM

Document Has Been Signed on 12/02/2021 10:16 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:NEW HAVENFACILITY NUMBER:
079200781
ADMINISTRATOR:ELIZABETH CORTES- PALADFACILITY TYPE:
740
ADDRESS:2236 WHYTE PARK AVENUETELEPHONE:
(510) 965-5555
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94595
CAPACITY: 6CENSUS: 0DATE:
12/02/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Marilou LadabanTIME COMPLETED:
10:25 AM
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On 12/2/2021 at 9:15 am Licensing Program Analysts (LPAs) G. Clark and L. Francisco arrived unannounced to conduct Infection Control Inspection. LPAs met with Marilou Ladabon and explained the purpose of the visit. There are currently no residents at this facility.

During the Infection Control Inspection, LPAs toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and backyard. There is one central entry point for universal screening for staff, residents and visitors. LPAs observed walls were recently painted and all posters were removed. Facility staff were observed to be wearing proper PPE. Facility has a mitigation plan on file.

No deficiencies cited during visit. Exit interview conducted and due to technical issues a copy of this report provided via email.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE: DATE: 12/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/02/2021
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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