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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601211
Report Date: 10/21/2020
Date Signed: 10/23/2020 04:31:46 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:WELCOME HOME SENIOR RESIDENCEFACILITY NUMBER:
015601211
ADMINISTRATOR:RAMOS, DIGNAFACILITY TYPE:
740
ADDRESS:7693 DONOHUE DRIVETELEPHONE:
(510) 685-8388
CITY:DUBLINSTATE: CAZIP CODE:
94568
CAPACITY:6CENSUS: 6DATE:
10/21/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Steve ChouTIME COMPLETED:
03:25 PM
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On 10/21/20 at 3:15pm LPA Allison O'Hollaren conducted an unannounced case management visit to perform a health and safety check of the facility, meeting with Administrator S1. Due to the State's current COVID-19 shelter in place order the visit was conducted by tele-visit. An explanation for the purpose of the visit was provided.

A tour of the interior and exterior of the physical plant was made. The facility is adequately clean and organized. The electricity, gas, and water were all operational. There was adequate 7 days non-perishable and 2 days perishable foods in stock. There was no trash buildup. Residents were present; none exhibited obvious marks, scratching, or bruising. Residents were adequately groomed and attired. Two staff were present.

This report was reviewed with S1 and a copy of the report was provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Allison O'HollarenTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2020
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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