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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200375
Report Date: 02/01/2024
Date Signed: 02/01/2024 02:24:17 PM

Document Has Been Signed on 02/01/2024 02:24 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:NICOLET II CARE HOMEFACILITY NUMBER:
019200375
ADMINISTRATOR:JUDY D. SALAZARFACILITY TYPE:
735
ADDRESS:2564 EARLY RIVERS COURTTELEPHONE:
(510) 429-8747
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 6DATE:
02/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Judy SalazarTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) arrived unannounced to conduct annual required inspection and met with Administrator Judy Salazar. LPA explained to Salazar the purpose of visit. The facility is licensed for 6 and has an approved fire clearance for 4 non ambulatory clients. It is a Level 4F home vendorized by the Regional Center of the East Bay (RCEB). There were no clients observed during the visit. The Administrator states all clients are in their respective day programs.

LPA inspected the facility inside and out including but not limited to client bedrooms, bathrooms, dining, kitchen, garage and backyard areas. The facility was observed with sufficient supply of perishable and non perishable foods. There was ample supply of sheets, towels and warm blankets available for use of clients.
Hygiene products were also observed. A fire extinguisher was observed in the kitchen with inspection tag date of 8/7/2023. Hot water measured at 105 Fahrenheit. First aid kit was observed complete. Smoke detector and carbon monoxide were tested and observed functional.

At 12:40 pm, LPA reviewed P&I money and log with the Administrator. The facility has sufficient amount of bond to cover cash being handled at one time. At 12:54pm, LPA reviewed 5 client and 5 staff files. At 2:10 pm, LPA interviewed 2 clients and staff.

There are no deficiencies noted for this visit.

A copy of this report was provided to the Administrator.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/01/2024
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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