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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200266
Report Date: 07/21/2023
Date Signed: 07/21/2023 03:16:35 PM

Document Has Been Signed on 07/21/2023 03:16 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:STACY STREET FACILITYFACILITY NUMBER:
019200266
ADMINISTRATOR:NORMAN GOOLSBY SR.FACILITY TYPE:
735
ADDRESS:4961 STACY STREETTELEPHONE:
(510) 638-8460
CITY:OAKLANDSTATE: CAZIP CODE:
94605
CAPACITY: 6CENSUS: DATE:
07/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Norman Goolsby, Sr., AdministratorTIME COMPLETED:
03:25 PM
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On 7/21/23 at 1:35 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Norman Goolsby, Sr and explained the purpose of the visit. The facility’s fire clearance was approved for 6 ambulatory residents.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 3 total bedrooms which 3 bedrooms are occupied by the clients. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 72-degree Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the kitchen sink was measured at 106.5-degree Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. The supply of extra hygiene was available for clients. There is a minimum of one-week supply of non-perishables and 2-day perishables food supply.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 3/01/2023. First aid kit was observed to be complete. Fire drill was last conducted on 6/10/23.

At 1:40 p.m., 5 of 5 clients’ records were reviewed. At 2:10 p.m., 5 staff records were reviewed, and 5 of 5 have current first aid training and associated to the facility. A sample of 3 client’s medications were reviewed.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 7/21/23: LIC 610E Emergency Disaster Plan

No deficiencies were cited during this inspection. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE: DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2023
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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