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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201302
Report Date: 11/17/2023
Date Signed: 11/17/2023 02:19:05 PM

Document Has Been Signed on 11/17/2023 02:19 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:WARNER HOME #3FACILITY NUMBER:
019201302
ADMINISTRATOR:SLOAN, PAMELAFACILITY TYPE:
735
ADDRESS:36951 MULBERRY STREETTELEPHONE:
(831) 917-2870
CITY:NEWARKSTATE: CAZIP CODE:
94560
CAPACITY: 6CENSUS: 0DATE:
11/17/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Pamela Sloan/Armand GalleonTIME COMPLETED:
01:15 PM
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On this day at around 10 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived announced and met with applicants Pamela Sloan and Armand Galleon.

The application is for 6 ambulatory clients. Fire clearance was approved on 10/11/2023.

During the visit, LPA inspected the facility inside and out including but not limited to bedrooms, kitchen, dining area, bathrooms, garage and backyard. The facility has 3 bedrooms and 2 bathrooms. There were no bodies of water observed. The facility has sufficient lighting and appropriate furnishings. There was sufficient supply of sheets, towels, warm blankets, hygiene products, plates, fork, glasses and other kitchen utensils observed. Food supplies were also observed. Facility is equipped with refrigerator, microwave, dishwasher, washer and dryer. Fire extinguisher in the kitchen appeared full and was purchased on 10/10/2023. Smoke detectors and carbon monoxide were tested and observed operational. First aid kit was observed complete. There is a locked cabinet for medications and resident/staff files. A separate locked cabinet is observed for sharp objects and chemicals. Hot water measured at 119 degrees Fahrenheit.

Complaint and Personal Rights posters were observed posted in the dining area. Facility has PPEs readily available. COVID-19 central screening station was observed by front entrance door with no touch probe thermometer, hand sanitizer and Visitor's Log.

During the visit, applicants did the following:
  • placed an order for activity materials that will be delivered on the same day and Sunday
  • placed an order for 7-piece patio dining set and awning that will be delivered between 11/22-11/27 for the backyard
  • activated telephone line and should be accessible by Monday, 11/27/2023
continuation on Lic 809C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2023
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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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: WARNER HOME #3
FACILITY NUMBER: 019201302
VISIT DATE: 11/17/2023
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LPA was provided proof of purchase for the materials/furniture ordered.

The applicants will notify and submit proof of delivery to LPA once orders arrive. Applicant will call LPA from facility phone line to confirm activation.

LPA observed that facility is ready to be licensed. This report will be submitted to the Centralized Application Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2023
LIC809 (FAS) - (06/04)
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