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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201255
Report Date: 05/17/2023
Date Signed: 05/17/2023 04:06:38 PM

Document Has Been Signed on 05/17/2023 04:06 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:DONOHUE CARE HOMEFACILITY NUMBER:
019201255
ADMINISTRATOR:YOUNG, KIMFACILITY TYPE:
735
ADDRESS:7513 DONOHUE DRTELEPHONE:
(510) 909-3458
CITY:DUBLINSTATE: CAZIP CODE:
94568
CAPACITY: 3CENSUS: 0DATE:
05/17/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Young Kim, AdministratorTIME COMPLETED:
04:30 PM
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On 5/17/2023 at 2:00PM, Licensing Program Analysts (LPAs) K. Nguyen schedule an appointment with Administrator/ Licensee, Young Kim conduct Pre-licensing Inspection. The facility is a new facility, and currently doesn’t have any clients. Upon arrival, LPAs met with Young Kim Administrator/Licensee, and explained the purpose of the visit.

LPA toured facility including but not limited to 3 bedrooms, 2 bathrooms, kitchen, common areas and backyard. Bedrooms and living rooms were equipped with the proper furniture Linens and hygiene supplies were observed inside a cabinet. There is sufficient lighting throughout facility. Room temperature was maintained at 73 degrees F. Smoke detectors and carbon monoxide were operational. Fire extinguisher was last serviced on 11/22/2022.

Report continue on LIC 809c...

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2023
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 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: DONOHUE CARE HOME
FACILITY NUMBER: 019201255
VISIT DATE: 05/17/2023
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LPAs observations:

In the client’s bathroom LPA observed that there were no non-skid mats. Measurements of hot water temperature was at 126 degrees F. First-aid kit was observed to be not complete. Multiples objects are blocking the exit path, garbage bags on the side of the pathway. Sharp objects are not being locked, and chemical are not being lock. Signs are not being posted (visiting policy, administrator certificate, etc.). Facility doesn’t have perishable food.

LPAs observed that facility is not ready to be licensed. Comp III was not conducted due to facility not ready to be licensed.

Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
LIC809 (FAS) - (06/04)
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