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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201203
Report Date: 11/09/2022
Date Signed: 11/09/2022 11:46:16 AM

Document Has Been Signed on 11/09/2022 11:46 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:EMPOWERING VISIONS IIIFACILITY NUMBER:
019201203
ADMINISTRATOR:ONWURAH, ANNETTEFACILITY TYPE:
735
ADDRESS:2751 75TH AVETELEPHONE:
(510) 710-2117
CITY:OAKLANDSTATE: CAZIP CODE:
94605
CAPACITY: 3CENSUS: 0DATE:
11/09/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Corshema Taylor, LicenseeTIME COMPLETED:
11:55 AM
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On 11/09/2021 at 11:00 am, Licensing Program Analyst (LPA) Greg Clark conducted an announced Pre-licensing Inspection and met with Licensee, Corshema Taylor. The facility currently has no clients. Fire clearance is approved for ambulatory clients only.

During the visit, LPA toured facility including but not limited to bedrooms, bathrooms, dining room, common area, kitchen, and backyard. There is sufficient lighting around the facility. Client rooms are equipped with the proper furniture and lighting. Client's rooms have proper bedding and linens for the client's to use. The kitchen was observed cleaned and within compliance. Bathroom is equipped with grab bars and hygiene items. Living room is equipped with the proper furniture for the clients. Cleaning supplies and sharp objects are locked and inaccessible. Passageways and hallways are free of obstruction. Fire extinguisher is in compliance. Smoke detectors and Carbon Monoxide detector are observed throughout the facility. Medication cabinet has a lock and first aid kit is complete. Hot water temperature is measured at 112.2 degrees Fahrenheit.

Licensee currently operates another ARF. Component III is being waived.

No issues noted during inspection. 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.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2022
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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