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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201255
Report Date: 12/05/2024
Date Signed: 12/05/2024 11:32:59 AM

Document Has Been Signed on 12/05/2024 11:32 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:DONOHUE CARE HOMEFACILITY NUMBER:
019201255
ADMINISTRATOR/
DIRECTOR:		YOUNG, KIMFACILITY TYPE:
735
ADDRESS:7513 DONOHUE DRTELEPHONE:
(510) 909-3458
CITY:DUBLINSTATE: CAZIP CODE:
94568
CAPACITY: 3CENSUS: 0DATE:
12/05/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:25 AM
MET WITH:Administrator, Young KimTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 12/05/2024 at 10:25 AM, Licensing Program Analyst (LPA) Ardalan Gharachorloo arrived announced to conduct an inspection for licensee's capacity increase request for 6 Non-ambulatory clients. LPA met with Administrator, Young Kim and explained the purpose of the visit. The facility currently has no clients.

LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common areas and backyard. Bedrooms and living rooms were equipped with the proper furniture. Bathrooms were equipped with grab bars and non-skid mats. Linens and hygiene supplies were observed inside a cabinet. There is sufficient lighting throughout facility.Hot water temperature was maintained at 113.2 degrees F. First-aid kit was observed to be complete. Smoke detectors and carbon monoxide were operational. Fire extinguisher was last serviced on 11/21/2024. LPA also observed a locked cabinet for centrally stored medications.

At 11:20 AM LPA reviewed Licensee's records and all were complete.


No issues noted during inspection. LPAs observed that facility is ready for capacity increase and Non-ambulatory clients.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Ardalan Gharachorloo
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2024
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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