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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201108
Report Date: 02/24/2022
Date Signed: 02/24/2022 02:03:28 PM


Document Has Been Signed on 02/24/2022 02:03 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:HEALTHY LIVING RESIDENTIAL CARE, INC.FACILITY NUMBER:
019201108
ADMINISTRATOR:BOOKER, JOSEFINAFACILITY TYPE:
740
ADDRESS:1179 VIA LUCASTELEPHONE:
(510) 397-0326
CITY:SAN LORENZOSTATE: CAZIP CODE:
94580
CAPACITY:6CENSUS: 5DATE:
02/24/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Josefina Booker, AdministratorTIME COMPLETED:
01:15 PM
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On 02/24/22 at 10:00 am, Licensing Program Analysts (LPAs) C. Fowler and L. Hall conducted an unannounced pre-licensing inspection (facility is in operation and changing ownership). LPAs met with Josefina Booker Administrator, and explained the reason for the visit. The facility has an approved fire safety clearance for six (6) non-ambulatory clients, all may be non-ambulatory. During inspection LPA observed four (4) clients and two (2) staff.

LPAs inspected the facility inside and out including but not limited to the bedrooms, bathrooms, common living areas, kitchen, garage and backyard. The facility has a total of five (5) bedrooms and two (2) bathrooms. There were no bodies of water present during inspection. There is sufficient lighting around the facility. Clients rooms are equipped with the proper furniture, bedding, and lighting. Bathrooms showers/tubs were equipped with non skid mats. Passageways and hallways are free of obstruction. Locked cabinets available to store medications, toxins and sharps. Required posters are posted on the wall. Fire extinguisher was last serviced on 08/22/2021. First Aid kit was complete. Carbon monoxide and smoke detectors present.

Prior to licensure, the following shall be corrected and submitted to CCLD by 02/25/2022.

A photo of water temperature. Temperature should be between 105 and 120 degree F.

Issues were noted during inspection. LPAs observed that facility is not 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 Administrator and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2022
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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