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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201162
Report Date: 03/16/2022
Date Signed: 03/16/2022 10:56:24 AM

Document Has Been Signed on 03/16/2022 10:56 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:DEBBIE'S CARE HOMEFACILITY NUMBER:
019201162
ADMINISTRATOR:PICKENS, DEBRAFACILITY TYPE:
735
ADDRESS:6008 MARTIN LUTHER KING JR WAYTELEPHONE:
(510) 812-2127
CITY:OAKLANDSTATE: CAZIP CODE:
94609
CAPACITY: 4CENSUS: 0DATE:
03/16/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Debra Pickens, AdministratorTIME COMPLETED:
11:10 AM
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On 03/16/22 at 9:00 AM. Licensing Program Analyst (LPA) Catherine Lin arrived announced to conduct Pre-licensing Required inspection. LPA met with Administrator, Debra Pickens and explained the purpose of the visit. The facility currently has no clients.

LPA toured facility including but not limited to 2 bedrooms, 1 bathroom, kitchen, common area and backyard. Bedrooms and living rooms were equipped with the proper furniture. Bathroom was equipped with non-skid mats. Linens and hygiene supplies were observed inside a cabinet. There is sufficient lighting throughout facility. Room temperature was maintained at 68 degrees F and hot water temperature was maintained at 117 degrees F. First-aid kit was observed to be complete. A combination detector of smoke and carbon monoxide was operational. Fire extinguisher was last serviced on 03/07/2022.

Prior to licensure, the following shall be corrected and submitted to CCL by 03/18/2022.
  • 5 out of 7 windows have no screens, 1 window screen was broken and required to be replaced.
  • One of the night stand drawers doesn't not close properly and required to be repaired.
  • 30-day of PPE supplies is not adequate, facility has no gown, face shield and N95 respiratory. Administrator contacted Regional Center where will provide PPE to facility.

Issues were noted during inspection. LPA 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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE: DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/16/2022
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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