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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600463
Report Date: 10/14/2020
Date Signed: 10/14/2020 04:15:50 PM

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:CROW CANYON RESIDENTIAL CARE IIFACILITY NUMBER:
015600463
ADMINISTRATOR:YU, RUFFY B.FACILITY TYPE:
740
ADDRESS:4632 SHASTA CT.TELEPHONE:
(925) 931-0213
CITY:PLEASANTONSTATE: CAZIP CODE:
94566
CAPACITY:6CENSUS: 4DATE:
10/14/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:25 PM
MET WITH:Loida Tamayo, House ManagerTIME COMPLETED:
04:15 PM
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On 10/14/2020 at 3:25PM, Licensing Program Analyst (LPA) G. Luk conducted a Case Management Tele-visit regarding an incident report via FaceTime due to shelter in place order directed by the Governor. LPA spoke to House Manager, Loida Tamayo.

Based on the incident report received on 10/9/2020, facility staff discovered that the newly installed flooring was starting to warp. The landlord was notified and later found a big pool of water underneath the house. Some of the old water pipelines were leaking.

During Tele-Visit, LPA toured the facility including the areas that had water leakage. LPA observed that facility has running water available for residents. Flooring in the affected area was located on the door of the water heater which was closed off by a latch on top of the door. LPA did not observe warped flooring in hallway, common area, and bathroom. LPA observed resident's bedrooms are carpeted. LPA observed some staples on hallway flooring near the hallway bathroom towards the back of the house. LPA observed the staples were secure and were not protruding from flooring.

LPA received relocation plans from Licensee, Ruffy Yu on 10/7/2020.

No deficiencies are being cited on this date.

Exit interview conducted and a copy of this report will be emailed.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2020
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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