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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201190
Report Date: 10/31/2022
Date Signed: 10/31/2022 11:57:11 AM

Document Has Been Signed on 10/31/2022 11:57 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:QUALITY CARE ADULT PROGRAM - 33RD STREETFACILITY NUMBER:
019201190
ADMINISTRATOR:MONTGOMERY, CHADFACILITY TYPE:
735
ADDRESS:624 33RD STREETTELEPHONE:
(510) 922-1936
CITY:OAKLANDSTATE: CAZIP CODE:
94609
CAPACITY: 4CENSUS: 0DATE:
10/31/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Chad Montgomery and Jamese Victoria Walters, Applicants/AdministratorsTIME COMPLETED:
12:15 PM
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On 10/31/22 at 9:00 AM, Licensing Program Analyst (LPA) C. Lin arrived announced to conduct Pre-licensing Required inspection. LPA met with applicants, Jamese Victoria Walters and Chad Montgomery and explained the purpose of the visit. The facility currently has no clients.

LPA toured facility including but not limited to 4 bedrooms, 2 bathrooms, kitchen, common areas and backyard. Bedrooms and living rooms were equipped with the proper furniture. Bathrooms were equipped with non-skid mats. There is sufficient lighting throughout facility. First-aid kit was observed to be complete. Smoke detectors and carbon monoxide were operational. Fire extinguishers were last purchased on 10/25/2022.

Prior to licensure, the following shall be corrected and submit to CCL by 11/18/2022.

  • Grab bars in the bathrooms may be required.
  • Bedroom 1 door lock needs to be fixed; bedroom 2 door and lock need to be fixed.
  • Bathrooms both door locks between bedrooms 1 & 2 need to be fixed.
  • Water temperature was 129.8 degrees F, needs to be adjusted to 105-120 degrees F.
  • Walls, floors window screens, kitchen cabinet, and areas around the facility need to be cleaned, painted, and in good repair.
  • Backyard fences need to be fixed, tools and chemical need to be locked, junks needs to be removed.
  • Laundry room needs to be cleaned.
  • Extra refrigerator and freezer may be required.

Continue on 809-C

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE: DATE: 10/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2022
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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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: QUALITY CARE ADULT PROGRAM - 33RD STREET
FACILITY NUMBER: 019201190
VISIT DATE: 10/31/2022
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  • Check the central heater and make sure room temperature is maintained at a comfortable level.
  • Infection control posters need to be posted throughout the facility.
  • 30-days of PPE supplies are required.

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.

COMP III has not been provided at this day visit.

Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2022
LIC809 (FAS) - (06/04)
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