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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201322
Report Date: 07/24/2024
Date Signed: 07/24/2024 03:57:08 PM

Document Has Been Signed on 07/24/2024 03:57 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:G & C RESIDENTIAL-74TH AVENUEFACILITY NUMBER:
019201322
ADMINISTRATOR/
DIRECTOR:		JOHN F COOLEYFACILITY TYPE:
735
ADDRESS:1661 74TH AVENUETELEPHONE:
(919) 960-1906
CITY:OAKLANDSTATE: CAZIP CODE:
94621
CAPACITY: 6CENSUS: 3DATE:
07/24/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:John Cooley, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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On 7/24/24 at 2:30 PM, Licensing Program Analyst (LPA) Greg Clark arrived announced to conduct pre-licensing inspection. LPA met with Administrator, John Cooley and explained the purpose of the visit. The facility currently has 3 residents residing under the existing license.

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. First-aid kit was observed to be complete. Smoke detectors and carbon monoxide were operational. Fire extinguisher was last serviced on 1/11/24.

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 conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE: DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2024
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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