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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201190
Report Date: 01/25/2023
Date Signed: 01/25/2023 11:21:26 AM

Document Has Been Signed on 01/25/2023 11:21 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:
01/25/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Chad Montgomery and Jamese Victoria Walters, Applicants/AdministratorsTIME COMPLETED:
10:30 AM
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On 1/25/23 at 9:20 AM, Licensing Program Analyst (LPA) C. Lin arrived announced to conduct Pre-licensing re-inspection. LPA met with applicants, Jamese Victoria Walters and Chad Montgomery and explained the purpose of the visit. The facility currently has no client.

LPA toured facility and observed that the following corrections were made and in compliance.

  • Grab bars in the bathrooms were installed.
  • Bedroom 1 door lock has been replaced with a new lock; bedroom 2 door and lock have been repaired.
  • Bathrooms both door locks between bedrooms 1 & 2 have been replaced with new locks.
  • Water temperature was observed at 106.6 degrees F.
  • Walls, floors, window screens, kitchen cabinet, and areas around the facility were clean, painted, and in good repair.
  • Backyard fences have been replaced, tools and chemical were locked, junks were removed.
  • Laundry room was clean.
  • Extra refrigerator with freezer was purchased and placed in the laundry room.
  • The central heater has been disable. Portable heaters were placed in living room and each bedroom. Room temperature was observed at 68 degrees F during visit.
  • Infection control signs were posted in the facility.
  • 30-days of PPE supplies are adequate.

Continue on LIC809-C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE: DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/25/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 01/25/2023
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No issues noted during re-inspection on today's date. 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.

LPA advised applicants that they must inform licensing within 5 business days that they have accepted the first client.

Exit interview conducted and a copy of this report provided.

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

DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023
LIC809 (FAS) - (06/04)
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