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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200809
Report Date: 04/11/2023
Date Signed: 04/11/2023 11:33:52 AM

Document Has Been Signed on 04/11/2023 11:33 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:EMPOWERING VISIONSFACILITY NUMBER:
019200809
ADMINISTRATOR:TAYLOR, CORSHEMAFACILITY TYPE:
735
ADDRESS:2404 WARNER AVETELEPHONE:
(510) 567-3603
CITY:OAKLANDSTATE: CAZIP CODE:
94603
CAPACITY: 2CENSUS: 2DATE:
04/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Corey McDonald, Caregiver
Corshema Taylor, Administrator		TIME COMPLETED:
11:45 AM
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On 4/11/2023 at 9:00 AM, Licensing Program Analyst (LPA) P. Watson arrived unannounced to conduct Required 1 Year Annual inspection. LPA met with Caregiver, Corey McDonald and explained the purpose of the visit. Administrator, Corshema Taylor, joined the visit at 10:12 AM The facility’s fire clearance was approved for 2 Ambulatory.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 2 total bedrooms which both bedrooms are occupied by the clients. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 75 degree Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 116 degree Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. There is a minimum of 7 day supply of non-perishables and 2 day perishables food supply.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 12/09/2022. Emergency Disaster Drill was last posted on 3/20/2023. First aid kit was observed to be complete. Fire drill was last conducted on 3/19/2023.

At 9:58 AM, clients’ records were reviewed. At 10:15 AM, 5 staff records were reviewed, and 5 of 5 have current first aid training and associated to the facility. A sample of client’s medications were reviewed.

Report continues on 809 C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Paris Watson
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: EMPOWERING VISIONS
FACILITY NUMBER: 019200809
VISIT DATE: 04/11/2023
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Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 4/26/2023:


LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 400 Affidavit Regarding Client/Resident Cash Resources
LIC 402 Surety Bond
LIC 610D Emergency Disaster Plan



No deficiencies were cited during this inspection.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Paris Watson
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023
LIC809 (FAS) - (06/04)
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