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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200315
Report Date: 10/05/2023
Date Signed: 10/05/2023 01:16:52 PM

Document Has Been Signed on 10/05/2023 01:16 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:SHADYSPRINGFACILITY NUMBER:
019200315
ADMINISTRATOR:BRANDIE KELBERFACILITY TYPE:
735
ADDRESS:21763 SHADYSPRING ROADTELEPHONE:
(510) 538-8330
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94546
CAPACITY: 3CENSUS: 2DATE:
10/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Brandie Kelber, AdministratorTIME COMPLETED:
01:25 PM
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On 10/5/2023 Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct 1-Year Annual Required Visit on this date starting at 9:50am. Upon arrival, LPA met with Lead staff Alemi Najia and explained the purpose of the visit, later Administrator, Brandie Kelber arrived at 10:35am. The facility's fire clearance was approved for all may be non-ambulatory.

LPA toured facility with lead staff 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 72 degrees F. Hot water temperature measured at 116 degrees F. There is a minimum of one-week nonperishable foods supply and 2-day perishable foods. Hygiene supplies are readily available for Clients. Smoke detectors are interconnected with sprinklers. Carbon monoxide was in working condition. First aid was observed completely. The fire extinguisher was last serviced on 10/20/2023.

LPA reviewed 2 clients records. LPA reviewed 3 staff records and 3 of 3 have current first aid training and associated to the facility. LPA reviewed 2 clients medications.


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: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/05/2023
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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