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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200811
Report Date: 02/22/2023
Date Signed: 02/22/2023 08:47:16 PM

Document Has Been Signed on 02/22/2023 08:47 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:AIHOUSEFACILITY NUMBER:
079200811
ADMINISTRATOR:LI, AIYANFACILITY TYPE:
740
ADDRESS:1605 ARLINGTON BLVDTELEPHONE:
(510) 529-6766
CITY:EL CERRITOSTATE: CAZIP CODE:
94530
CAPACITY: 6CENSUS: 0DATE:
02/22/2023
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME BEGAN:
04:40 PM
MET WITH:Aiyan Li, AdministratorTIME COMPLETED:
05:20 PM
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On 02/22/2023 at 04:40 PM, Licensing Program Analyst (LPA) L. Holmes arrived announced to conduct annual infection control inspection. Upon arrival LPA was greeted by Aiyan Li (ADM) to conduct the inspection.

Facility has a COVID-19 mitigation plan on file. There are not any residents at this time. LPA observed a screening station; facility has a thermometer, hand sanitizer, masks, gloves, and COVID-19 signage. LPA and ADM toured the facility including, but not limited to common areas, bathroom, bedrooms, kitchen, garage, and backyard. LPA observed mask, cough etiquette, social distancing and hand washing signs posted throughout. ADM to post 20 seconds to hand washing signs in the kitchen. There was a sufficient supply of PPE. All hand washing stations were equipped with soap, paper towels and covered garbage cans. The hot water temperature in the shared residents' bathroom was measured at 113 degree Fahrenheit (F). Fire extinguisher was observed full. Smoke/Carbon Monoxide detectors were observed operational and first aid kit complete.

The following forms are to be updated and submitted to CCLD when new residents are admitted:
-LIC500 Personnel Report (Received)
-LIC308 Designation of Administrative Responsibility
-LIC610 Emergency Disaster Plan (Reviewed)
-An updated copy of Administrator Certificate(s); Expires 09/20/2024
-Infection control Plan (ICP) due 03/08/2023

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2023
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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