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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201167
Report Date: 07/22/2022
Date Signed: 07/22/2022 04:43:17 PM


Document Has Been Signed on 07/22/2022 04:43 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:ELEGANCE AT DUBLINFACILITY NUMBER:
019201167
ADMINISTRATOR:COONS, JENNIFERFACILITY TYPE:
740
ADDRESS:7601 AMADOR VALLEY ROADTELEPHONE:
(360) 836-4604
CITY:DUBLINSTATE: CAZIP CODE:
94568
CAPACITY:80CENSUS: 37DATE:
07/22/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Jennifer Coons, Executive Director TIME COMPLETED:
04:55 PM
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On 7/22/2022 at 1:55PM, Licensing Program Analysts (LPAs) K. Nguyen, and L. Francisco arrived unannounced to conduct Pre-licensing Inspection. Facility is currently licensed and pre-licensing is requested due to change of ownership. Upon arrival, LPAs met with Nabila Shah Business Office Manager and explained the purpose of the visit. Jennifer Coons, Executive Director later arrived at 3:30PM.

LPAs toured facility with Business Office Manager including but not limited to random 5 residents’ apartment, common areas, multiple activity rooms, kitchen, laundry room, and front patio. Passageways and hallways are free of obstruction. Required posters are posted on the wall with Emergency Disaster Plan. A comfortable room temperature is maintained at 73 degrees Fahrenheit (F) in the lobby room. Each residents’ apartment is equipped with a heating and cooling unit. Refrigerator temperature is maintained at 30 degrees F and freezer temperature is maintained at 0 degrees F. Fire extinguisher was last serviced on 9/10/21. First Aid kit was complete. Carbon monoxide/smoke detectors were observed and interconnected with the sprinkler system 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.

No issues noted during inspection. LPAs 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 and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2022
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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