<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201193
Report Date: 11/22/2022
Date Signed: 11/22/2022 10:40:04 AM

Document Has Been Signed on 11/22/2022 10:40 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:RACHELL'S FACILITYFACILITY NUMBER:
019201193
ADMINISTRATOR:EVANS, RACHELLFACILITY TYPE:
735
ADDRESS:33103 8TH STREETTELEPHONE:
(510) 331-2598
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 4CENSUS: 0DATE:
11/22/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Rachell Evens, LinceseeTIME COMPLETED:
10:45 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPA) J. Clancy-Czuleger, conducted an announced visit to the facility for the purpose of a Pre-Licensing evaluation. LPA meet with Rachell Evens (applicant-licensee).

LPA inspected the facility inside and out. There is no body of water. Physical plant is consistent with the facility sketch received by Central Application Bureau (CAB) and approved by the fire department. LPA's inspected the living room, dining area, kitchen, bedrooms, hallways, bathrooms, side and backyards. Bedrooms were observed appropriately furnished with adequate lighting and drawers. Facility has sufficient towels, extra bed sheets and comforters. Equipment and supplies for residents' personal hygiene are available and on site. Dinner and silver wares were observed sufficient for residents' use. Food supplies checked and observed good for seven days of non-perishables. Facility was observed equipped with refrigerator, microwave, dishwasher, washer and dryer. Cabinet cleaning supplies, and central storage for medications were observed with locks, along with a lock box for knifes and sharp objects. Activity supplies were available. Outdoor activity space was observed furnished with tables, chairs and shade.

Fire extinguishers were observed fully charge and tags showed serviced February 24, 2022. The two-in-one carbon monoxide and smoke detector tested and observed functional. First aid kit checked and observed complete with manual. Hot water temperature in one of the bathrooms tested and measured at 119.2 degrees Fahrenheit. There are no corrections to be made.

An exit interview was conducted, and a copy of this report has been given. Accordingly, LPA will submit a copy of this facility evaluation report to the Centralized Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2022
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 1