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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200315
Report Date: 09/30/2022
Date Signed: 09/30/2022 03:41:14 PM

Document Has Been Signed on 09/30/2022 03:41 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:SHADYSPRINGFACILITY NUMBER:
019200315
ADMINISTRATOR:BRANDIE KELBERFACILITY TYPE:
735
ADDRESS:21763 SHADYSPRING ROADTELEPHONE:
(510) 538-8330
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94546
CAPACITY: 3CENSUS: 3DATE:
09/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Santiago Orellana, Direct Supoort ProfessionalTIME COMPLETED:
03:55 PM
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On 9/30/22 at 2:40 PM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct Infection Control Inspection. Upon arrival LPA got greeted by Direct Support Professional (DSP), Santiago Orellana and explained the purpose of the visit. LPA spoke with Administrator Brandie Kelber that could not be present during the inspection. Administrator gave verbal consent for DSP to assist LPA with the tour as sign the report.

LPA toured facility with DSP including but not limited to bedrooms, bathroom, kitchen, common area and backyard. Indoor and outdoor passageways are kept free of obstruction. A comfortable room temperature is maintained at 73 degrees F. Hot water temperature measured at 115 degrees F. There is a minimum of one week nonperishable foods supply and 2-day perishable foods. Hygiene supplies are readily available for residents. Smoke detectors are interconnected with sprinklers. Carbon monoxide was in working condition. . Fire extinguisher was last serviced on 7/7/22.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 10/07/2022:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
Current Administrator’s Certificate

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2022
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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