<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200484
Report Date: 09/29/2023
Date Signed: 09/29/2023 12:04:17 PM


Document Has Been Signed on 09/29/2023 12:04 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: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: 29DATE:
09/29/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Health Service Director, Carolyn Appeal TIME COMPLETED:
12:10 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 9/29/2023 at 11:30 AM, Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct a case management visit. LPA met with Health Service Director, Carolyn Appeal (HSD) and explained the purpose of the visit.

LPA went to the facility to deliver an Immediate Exclusion letter. It was confirmed S1 is currently employed at the facility. Immediate Exclusion letter was delivered to HSD. LPA has advised HSD to disassociate the individual from their roster and submit an updated LIC 500 to CCL. Facility called S1 and advised him of the immediate exclusion.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory ClarkTELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1