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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200086
Report Date: 05/31/2024
Date Signed: 05/31/2024 04:12:01 PM

Document Has Been Signed on 05/31/2024 04:12 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:SIR FRANCES ANN RESIDENTIALFACILITY NUMBER:
019200086
ADMINISTRATOR/
DIRECTOR:		DELLA A. CHAMBERS-BREWERFACILITY TYPE:
735
ADDRESS:1739 SCENICVIEW COURTTELEPHONE:
(510) 357-6995
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY: 6CENSUS: 5DATE:
05/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:40 PM
MET WITH:Pamela Temple, Direct Care StaffTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
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On 05/31/2024 at 12:40PM, Licensing Program Analyst (LPA) T.Syess-Gibson arrived to conducted an unannounced annual 1-Year required inspection. At 12:50PM LPA called Administrator Della Chambers-Brewer and left a message advising the purpose of visit. At 1:14PM LPA received a call from staff member Pamela Temple advising me of in route to the facility. At 1:20PM LPA met with Pamela Temple, caregiver, and explained the purpose of the visit. Administrator, Della Chambers, currently holds a certificate (#6012476735) . The facility’s fire clearance was approved for six (6) ambulatory clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, garage, and back yard. The facility consists of five (5) total bedrooms and three (3) bathrooms. One (1) bedroom used by staff. All indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 72 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 106.4 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Paper towel, and soap observed at all hand washing stations. The supply of extra hygiene was available for residents. There is a minimum of 7-day non-perishables and 2-day perishables foods.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 02/21/2024. Emergency Disaster Plan was last posted on 01/20/2024. Fire Drill last conducted on 05/06/2024. First aid kit was observed to be complete.

Continued LIC809C

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: SIR FRANCES ANN RESIDENTIAL
FACILITY NUMBER: 019200086
VISIT DATE: 05/31/2024
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Three (3) staff records were reviewed, and all staff have first aid certification. All Three (3) clients' records reviewed. LPA reviewed a sample of medication and P&I

The following forms to be updated and submitted to CCLD by 06/07/2024:

· Liability insurance.
· Surety Bond
· LIC500 (Updated Personnel Record)
· Client Roster
· LIC308 (Designation of facility Responsibility)
· LIC400 Affidavit Regarding Client/Resident Cash Resources

No deficiencies cited during visit.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024
LIC809 (FAS) - (06/04)
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