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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200487
Report Date: 02/25/2022
Date Signed: 02/25/2022 12:27:31 PM

Document Has Been Signed on 02/25/2022 12:27 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:CNS COURTYARD #146FACILITY NUMBER:
019200487
ADMINISTRATOR:STACEY MAGDEFRAUFACILITY TYPE:
735
ADDRESS:1465 65TH STREET, #146TELEPHONE:
(925) 719-5580
CITY:EMERYVILLESTATE: CAZIP CODE:
94608
CAPACITY: 2CENSUS: 2DATE:
02/25/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Ashley Cress, Case ManagerTIME COMPLETED:
12:40 PM
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On 2/25/2022 at 11:25AM, Licensing Program Analyst (LPA) C. Lin conducted an unannounced Health & Safety inspection as a result of a priority 1 complaint. LPA met with Case Manager, Ashley Cress. Administrator was absent and authorized Case Manager Ashley Cress sign on the report.

LPA toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, and outdoor area. Hot water temperature was measured at 120 degrees F in a resident's bathroom sink. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Facility staff takes residents to shop grocery every Saturday. Resident's medications and sharps were kept locked in the cabinet. First-aid kit was complete. Fire extinguisher was observed to be full and last serviced on 12/01/2021. Indoor and outdoor passageways are free of obstruction.

No deficiencies are being cited on this date.

Exit interview conducted. A copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE: DATE: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/25/2022
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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