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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700899
Report Date: 02/03/2025
Date Signed: 02/04/2025 09:07:09 AM

Document Has Been Signed on 02/04/2025 09:07 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:FRUITFUL HUMBLE ABODEFACILITY NUMBER:
392700899
ADMINISTRATOR/
DIRECTOR:		MABUNGA, JOYCE MAEFACILITY TYPE:
740
ADDRESS:1849 COIT STREETTELEPHONE:
(415) 619-9510
CITY:MANTECASTATE: CAZIP CODE:
95337
CAPACITY: 6CENSUS: 4DATE:
02/03/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Kherjee Reyes and Zenaida PranadaTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Unannounced Plan of Correction visit made out to this facility on 02/03/2025 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility staff persons, Kherjee Reyes and Zenaida Pranada, who were briefly interviewed at this time.
Current census was 4 residents..
The purpose of this visit was to follow up on the deficiencies that were cited from a prior annual visit conducted on 01/17/2025. This visit was to follow up on the Plan of Correction that was due.

The following deficiencies were observed and cited on 01/17/2025:
  • All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.
  • All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c)
Plan of Correction clearance letters were printed and copies were provided to the facility designated representatives at this time.

There were no further deficiencies observed or cited during today's Plan of Correction visit. Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 02/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2025
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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