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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201360
Report Date: 06/13/2024
Date Signed: 06/13/2024 11:10:51 AM

Document Has Been Signed on 06/13/2024 11:10 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:EMPOWERING VISIONS #4FACILITY NUMBER:
019201360
ADMINISTRATOR/
DIRECTOR:
TAYLOR, CORSHEMAFACILITY TYPE:
735
ADDRESS:27855 LANAI COURTTELEPHONE:
(510) 710-2117
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY: 4CENSUS: 0DATE:
06/13/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Anthony Taylor, AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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On 6/13/2024 at 9:00am, Licensing Program Analyst (LPA) K. Nguyen conducted an announced Pre-licensing Inspection and met with Licensee, Anthony Taylor. The facility currently has no clients. Fire clearance is approved for ambulatory clients only.

During the visit, LPA toured facility including but not limited to 3 bedrooms, 2 bathrooms, dining room, common area, kitchen, and backyard. There is sufficient lighting around the facility. Client rooms are equipped with the proper furniture and lighting. Client's rooms have proper bedding and linens for the client's to use. The kitchen was observed cleaned and within compliance. Bathroom is equipped with non-skit matt and hygiene items. Living room is equipped with the proper furniture for the clients. Cleaning supplies and sharp objects are locked and inaccessible. Passageways and hallways are free of obstruction. Fire extinguisher is in compliance. Smoke detectors and Carbon Monoxide detector are observed throughout the facility. Medication cabinet has a lock, and first aid kit is complete. Hot water temperature is measured at 110.8 degrees Fahrenheit.

Licensee currently operates another ARF. Component III is being waived.

No issues noted during inspection. LPA 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 via email.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/13/2024
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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