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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201190
Report Date: 01/21/2025
Date Signed: 01/21/2025 04:09:41 PM

Document Has Been Signed on 01/21/2025 04:09 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:QUALITY CARE ADULT PROGRAM - 33RD STREETFACILITY NUMBER:
019201190
ADMINISTRATOR/
DIRECTOR:		MONTGOMERY, CHADFACILITY TYPE:
735
ADDRESS:624 33RD STREETTELEPHONE:
(510) 922-1936
CITY:OAKLANDSTATE: CAZIP CODE:
94609
CAPACITY: 4CENSUS: 1DATE:
01/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Chad Montgomery AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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On 01/21/2025 at 03:00 PM, Licensing Program Analyst (LPA) D. Doidge arrived unannounced to conduct Required 1 Year Annual inspection. LPA met with Deon Hodge, ASC Worker, and explained the purpose of the visit. Administrator, Chad Montgomery, arrived around 3:40 PM.

LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 4 total bedrooms 1 of which are occupied by the residents. All outdoor and indoor passageways are kept free of obstruction. A comfortable temperature is maintained at 70 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 116 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum 7 day supply of nonperishable and 2 day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents.

Smoke detectors and carbon monoxide detectors were in operating condition during visit. First aid kit was observed to be complete. Fire extinguisher was last serviced on 05/14/2024. Fire drill was last conducted on 12/20/2024 and are conducted monthly.

LPA reviewed one (1) resident record and five (5) staff records all were complete.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: David Doidge
LICENSING EVALUATOR SIGNATURE: DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2025
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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