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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201000
Report Date: 11/09/2020
Date Signed: 11/09/2020 10:51:40 AM

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:ELEGANCE AT DUBLINFACILITY NUMBER:
019201000
ADMINISTRATOR:WHITTEMORE, WESLEYFACILITY TYPE:
740
ADDRESS:7601 AMADOR VALLEY BLVDTELEPHONE:
(360) 975-4709
CITY:DUBLINSTATE: CAZIP CODE:
94568
CAPACITY:80CENSUS: 0DATE:
11/09/2020
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Wesley Whittemore, Executive DirectorTIME COMPLETED:
11:00 AM
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On Monday, November 9, 2020 at 9:00 AM, Licensing Program Analyst (LPA) L. C. Phomphachanh conducted an announced Pre-Licensing Inspection. LPA met with Executive Director (ED), Wesley Whittemore via face-time. Due to the Shelter in Place Order set forth by the Governor, LPA was not able to conduct the inspection in person. Currently, there are no residents.

LPA toured the facility with ED, inside and out including but not limited to the resident apartments, common living areas, kitchen, laundry room, and various floors. Passageways and hallways are free of obstruction and no bodies of waters. Required posters are posted on the wall with Emergency Disaster Plan. Thermometer in hallway showed temperature as 68 degrees Fahrenheit (F). Refrigerator temperature was at 35 degrees F and freezer was set at 0 degrees F. Fire extinguisher was last serviced on 07/07/2020. First Aid kit was complete. Carbon monoxide/smoke detectors were in working condition and interconnected with the building. Resident's room have nonskid mats and grab bars by the toilet and in the showers. All resident rooms have pull button that is centrally connected to the front desk. Common areas, 3rd floor patio, and dining has been modified for social distancing.

LPA conducted Component III and COVID-19 protocol consultation with ED. Facility has implemented COVID-19 screening at front entrance.

No issues noted during inspection. LPA observed that facility is ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAU. Additional requirements may still be required.

Exit interview conducted with Executive Director and a copy of this report will be emailed PDF.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Celia PhomphachanhTELEPHONE: (510)286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2020
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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