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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201424
Report Date: 01/30/2025
Date Signed: 01/30/2025 09:11:04 AM

Document Has Been Signed on 01/30/2025 09:11 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:FOREVER CARE HOMES LLCFACILITY NUMBER:
019201424
ADMINISTRATOR/
DIRECTOR:		LACY, JAYNEFACILITY TYPE:
735
ADDRESS:418 WARDEN AVETELEPHONE:
(312) 342-5638
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY: 6CENSUS: 0DATE:
01/30/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:30 AM
MET WITH:Licensee, Jayne LacyTIME VISIT/
INSPECTION COMPLETED:
09:35 AM
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On 1/30/2025 at 7:30 AM, Licensing Program Analyst (LPA) A. Gomez arrived announced to conduct a pre-licensing inspection. LPA met with Licensee, Jayne Lacy and explained the purpose of the visit. The facility currently has no clients.

LPA toured facility with Licensee, Jayne Lacy including but not limited to 4 bedrooms, 2 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. Activities are available to the clients. There is sufficient lighting throughout facility. Room temperature was maintained at 68 degrees F and hot water temperature was maintained at 107.8 degrees F. First-aid kit was observed to be complete. Smoke detectors and carbon monoxide were operational. Fire extinguisher was last serviced on 01/03/2025.

COMP III conducted on a case management

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.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE: DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2025
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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