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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201021
Report Date: 11/14/2024
Date Signed: 11/14/2024 01:03:24 PM

Document Has Been Signed on 11/14/2024 01:03 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:M&E CAREFACILITY NUMBER:
079201021
ADMINISTRATOR/
DIRECTOR:		SANTOS, MARIA DELOSFACILITY TYPE:
740
ADDRESS:461 LIMERICK ROADTELEPHONE:
(510) 669-5015
CITY:PINOLESTATE: CAZIP CODE:
94564
CAPACITY: 6CENSUS: 3DATE:
11/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:MARIA DELOS SANTOS, ADMINISTRATORTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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On 11/14/2024 at 10:15AM, Licensing Program Analyst (LPA) Carol Fowler conducted an unannounced 1-Year Required inspection. LPA met with Administrator, Tess Bautista and explained the purpose of the visit. The facility’s fire clearance was approved for four (4) non-ambulatory and two (2) bedridden residents.

LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard. The facility consists of five (5) total bedrooms. There are two (2) full bathrooms. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature is maintained at 71 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Residents’ bathrooms are equipped with grab bars. Hot water temperature in the shared clients’ bathroom was measured at 111 degrees Fahrenheit. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 07/24/2024. Emergency Disaster Plan was last posted on 02/22/2024. First aid kit was observed to be complete.

Two (2) staff records were reviewed, and all staff have criminal record clearance and holds a current first aid/CPR certificate. Three (3) Clients records were reviewed all complete.


Exit interview conducted. A copy of appeal rights and this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
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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