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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200783
Report Date: 06/09/2021
Date Signed: 06/09/2021 11:54:35 AM

Document Has Been Signed on 06/09/2021 11:54 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:B. RUIZ CAREHOME 2FACILITY NUMBER:
079200783
ADMINISTRATOR:JAMIE RUIZFACILITY TYPE:
740
ADDRESS:30 MERGANSER CTTELEPHONE:
(925) 698-1207
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 6CENSUS: 6DATE:
06/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Jaime Ruiz and Joyce PeleaTIME COMPLETED:
12:00 PM
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On June 9, 2021 at 9:30 AM, Licensing Program Analyst (LPA) Leslie Ibo arrived unannounced to conduct an annual required inspection. LPA met with Administrator Jaime Ruiz and house manager Joyce Pelea and informed the purpose of visit. Facility has census of 6. HOSPICE WAIVER APPROVED FOR FOUR (4) RESIDENTS. Facility currently has 1 hospice resident.

LPA started the inspection with Jaime Ruiz and Joyce Pelea. LPA toured the facility inside and out including but not limited to common areas, resident rooms, bathrooms, kitchen, garage and backyard and side yard. 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 30 days.

Water temperature was tested in one of the bathrooms and measured at 108 degrees Fahrenheit. Fire extinguisher checked; tag showed inspected on March 2021.

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: 06/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/09/2021
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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