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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200484
Report Date: 07/05/2023
Date Signed: 07/05/2023 11:48:54 AM


Document Has Been Signed on 07/05/2023 11:48 AM - 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:SUNOL CREEK MEMORY CAREFACILITY NUMBER:
019200484
ADMINISTRATOR:ROSE, JESSICAFACILITY TYPE:
740
ADDRESS:5980 SUNOL BLVDTELEPHONE:
(925) 846-8283
CITY:PLEASANTONSTATE: CAZIP CODE:
94566
CAPACITY:46CENSUS: 31DATE:
07/05/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Jacqueline Scott, Business Office ManagerTIME COMPLETED:
12:00 PM
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On 7/5/2023 at 10:30AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a health and safety check as a result of a priority 1 complaint. LPA met with Business Office Manager, Jacqueline Scott.

LPA toured facility including but not limited to the resident bedrooms, bathrooms, common area, kitchen, and outdoor area. Hot water temperature was measured at 109.7 degrees F in a resident's bathroom sink. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Facility order food supplies twice a week. Refrigerator temperature was observed at 40 degrees F and freezer temperature was observed at 0 degrees F. Resident's medications were kept locked in the medication carts. Smoke detectors are interconnected with sprinkler system. Carbon monoxide detector observe. First-aid kit was complete. Fire extinguisher was observed to be full and last serviced on 6/29/2023. There are no accessible bodies of water observed.


No deficiencies are being cited on this date.


Exit interview conducted. A copy of this report was provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2023
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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