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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601095
Report Date: 07/07/2023
Date Signed: 07/07/2023 05:19:43 PM


Document Has Been Signed on 07/07/2023 05:19 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:HERITAGE ESTATESFACILITY NUMBER:
015601095
ADMINISTRATOR:BATTISTI, STEVEFACILITY TYPE:
740
ADDRESS:900 E STANLEY BLVDTELEPHONE:
(925) 373-3636
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY:65CENSUS: 54DATE:
07/07/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:25 PM
MET WITH:Susan Donaghy, Health & Wellness DirectorTIME COMPLETED:
05:35 PM
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On 7/7/2023 at 3:25PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit in regards to an SOC341 received on 7/1/2023. LPA met with Health & Wellness Director, Susan Donaghy and explained the reason for the visit.


During visit, LPA interviewed 1 resident and 1 staff. LPA obtained documents (staff roster with contact information, physician's report, care plan, emergency information, and corrective action plan).

LPA will need to conduct additional interviews and may return at a later time to follow up.


No deficiencies are being cited on this date.


Exit interview conducted. A copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2023
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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