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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200462
Report Date: 04/05/2024
Date Signed: 04/05/2024 06:40:50 PM

Document Has Been Signed on 04/05/2024 06:40 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:JULIAN FAMILY CAREHOMEFACILITY NUMBER:
019200462
ADMINISTRATOR/
DIRECTOR:		MARCIAL D. JULIANFACILITY TYPE:
740
ADDRESS:26798 CONTESSA STREETTELEPHONE:
(510) 783-5216
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY: 6CENSUS: 3DATE:
04/05/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
06:15 PM
MET WITH:Belinda Dela Cruz/Staff TIME VISIT/
INSPECTION COMPLETED:
06:45 PM
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On April 4, 2024 at 7:42 p.m., Marcial Julian, administrator, sent message to Licensing Program Analyst (LPA) Delmundo stating that R1 does not anymore have the medication in the room (deficiency section # 87465(h)(1)(C)),

On this day,. April 5, 2024, at 5:05 p.m., administrator submitted the LIC9098 and POC for deficiency section # 87465(a)(4) and stated that the medication was approved, filled and delivered on this day. While at the facility for other reason on this same day, LPA asked staff, Belinda Dela Cruz, if the 2 medications are delivered. The staff stated they will be delivered at around 7:00 p.m. LPA also checked and observed the medication that was observed in R1's room is now centrally stored and locked.

LPA called and spoke with the administrator and discussed the above. Administrator authorized Belinda Dela Cruz to sign and receive this report.

While still at the facility, R1's medications were delivered at 6:27 p.m.

Administrator to submit the in-service training for deficiency section # 87465(h)(1)(C).

Exit interview conducted and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/05/2024
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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