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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201255
Report Date: 06/23/2023
Date Signed: 06/23/2023 02:40:08 PM

Document Has Been Signed on 06/23/2023 02:40 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:
06/23/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Kim Young, AdministratorTIME COMPLETED:
02:50 PM
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On 6/23/2023 at 1:30PM, Licensing Program Analysts (LPAs) K. Nguyen arrived unannounced to conduct Pre-licensing Inspection correction. Upon arrival, LPAs met with Kim Young Administrator, and explained the purpose of the visit. The facility currently has no clients. LPA conducted COMP III and reviewed with administrator.

LPA toured facility including but not limited to 3 bedrooms, 2 bathrooms, kitchen, common areas and backyard. LPA observed there’s no obstruction blocking the exit door. LPA observed that cabinets all have locks. LPA tested both bathroom with water temperature measured at 106-degree F. LPA observed all posters are being posted near the front door entrance. LPA observed first aids kits completed.

No issues noted during inspection. LPAs 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 is conducted and an email copy of this report is provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2023
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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