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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201259
Report Date: 07/27/2023
Date Signed: 07/27/2023 04:32:42 PM

Document Has Been Signed on 07/27/2023 04:32 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:HEAVENLY CARE HOMEFACILITY NUMBER:
019201259
ADMINISTRATOR:ABBASI, SHAHIDFACILITY TYPE:
740
ADDRESS:36857 WALNUT ST.TELEPHONE:
(925) 963-4081
CITY:NEWARKSTATE: CAZIP CODE:
94560
CAPACITY: 6CENSUS: 0DATE:
07/27/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Shahid AbbasiTIME COMPLETED:
04:00 PM
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
On this day at around 1:05 pm, Licensing Program Analyst (LPA) Luisa Fontanilla conducted an announced pre-licensing inspection and met with Licensee/Applicant Shahid Abbas (Administrator Certificate#6050933740 expiration 2/5/2025).

The home has an approved fire clearance for 5 non ambulatory and 1 bedridden residents. The home has a total of 5 resident bedrooms and 2 bathrooms. There is one room designated for staff use.

LPA toured the facility with the Administrator. There were sufficient kitchen and dining wares observed. Separate locked cabinets for medicines and chemicals were observed. All the resident rooms were observed equipped with beds, mattress, chair, lamp, dresser and closet. There were hygiene products observed. Bathrooms were observed with grab bars and non skid mats.

Carbon monoxide and smoke detectors were tested and observed operational. There were no bodies of water observed. The facility has sufficient lighting and appropriate equipment/furniture available.

Licensee/Applicant will obtain and provide LPA photos of the following on or before Monday, July 31, 2023:
  • Ombudsman poster
  • Complaint poster in 20x26 size
  • activity supplies/materials
  • hot water temperature between 105F-120F

LPA will inform CAB analyst upon receipt of proof of corrections. Final review of application, and license to be granted by CAB. Exit interview was conducted and copy of this report was provided
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2023
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 4