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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601411
Report Date: 04/02/2021
Date Signed: 04/02/2021 11:22:53 AM

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 RESIDENCE (PLEASANTON)FACILITY NUMBER:
015601411
ADMINISTRATOR:VELASCO,J & CHOU, SFACILITY TYPE:
740
ADDRESS:6839 SINGLETREE COURTTELEPHONE:
(510) 685-8388
CITY:PLEASANTONSTATE: CAZIP CODE:
94588
CAPACITY:6CENSUS: 5DATE:
04/02/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:21 AM
MET WITH:Julita VelascoTIME COMPLETED:
11:20 AM
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On 04/02/2021 at 10:21am, Licensing Program Analyst (LPA) Allison O'Hollaren contacted facility to conduct a case management inspection via televisit to ensure the health and safety of residents in care due to management directive. LPA spoke to Licensee, Steve Chou and explained the purpose of tele-visit. Licensee stated he is currently not in the facility and provided LPA’s contact information to staff. At 10:30am, Staff, Julita Velasco contacted LPA.

During the televisit via Facetime, LPA instructed staff to start from front entrance. LPA inspected including but not limited to screening station, residents’ room, bathrooms, common areas, kitchen, and food supplies. LPA observed room temperature was maintained at 72 degrees F. Facility has electricity and running water. LPA observed hot water was maintained at 110 degrees F. LPA observed 2-day perishable and one week non-perishable food supply. LPA observed centrally stored medication cabinet locked. LPA observed residents appear to be well groomed.

No deficiencies cited. Exit interview with Steve Chou and a copy of report provided via email.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Allison O'HollarenTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2021
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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