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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200664
Report Date: 09/29/2022
Date Signed: 09/29/2022 05:54:05 PM


Document Has Been Signed on 09/29/2022 05:54 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:COLONIAL ACRES RESIDENTIAL CARE HOMEFACILITY NUMBER:
019200664
ADMINISTRATOR:SARAH MAY BALINGITFACILITY TYPE:
740
ADDRESS:18905 STANDISH AVENUETELEPHONE:
(510) 276-0939
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:20CENSUS: 13DATE:
09/29/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:John Ronald Olivarez/Licensee and
Celeste Olivarez/Facilty Consultant		TIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Delmundo conducted a POC visit for the type A deficiency that was cited on November 9, 2021 for adding 3 rooms inside the staff bedroom. Licensee submitted the LIC9054 and updated sketch on January 3, 2022. LPA submitted the STD850 Fire Safety Inspection Request and updated sketch to the fire department; however, LPA has not receive the STD850 back. LPA followed-up with John Olivarez, licensee, who in-turn sent to LPA picture of the staff bedroom.

On this day, September 29, 2022, LPA met with John Ronald Olivarez, licensee, and Celeste Olivarez, facility consultant. LPA conducted inspection with Celeste Olivarez. LPA observed the 3 rooms that were added were removed and the staff bedroom were returned to it's original layout.

Exit interview conducted and copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2022
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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