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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200266
Report Date: 07/30/2024
Date Signed: 07/30/2024 02:58:50 PM

Document Has Been Signed on 07/30/2024 02:58 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/
DIRECTOR:		NORMAN GOOLSBY SR.FACILITY TYPE:
735
ADDRESS:4961 STACY STREETTELEPHONE:
(510) 638-8460
CITY:OAKLANDSTATE: CAZIP CODE:
94605
CAPACITY: 6CENSUS: 6DATE:
07/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Norman Goolsby, Sr. AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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On 7/30/24 at 1:30 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Norman Goolsby and explained the purpose of the visit

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 70-degree 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 105.8 degrees 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 4/10/24. Emergency Disaster Plan was last posted on 7/25/23. First aid kit was observed to be complete. Fire drill was last conducted on 6/20/24.

LPA reviewed 5 clients’ records and 5 staff records, and all were complete.

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: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/30/2024
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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