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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201531
Report Date: 03/10/2025
Date Signed: 03/10/2025 12:29:23 PM

Document Has Been Signed on 03/10/2025 12:29 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:EMPOWERING VISIONS IIIFACILITY NUMBER:
019201531
ADMINISTRATOR/
DIRECTOR:		TAYLOR,CORSHEMAFACILITY TYPE:
735
ADDRESS:28325 SPARROW ROADTELEPHONE:
(510) 710-2117
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY: 4CENSUS: 0DATE:
03/10/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Corshema Taylor/Applicant-Administrator
and Anthony Taylor/Applicant 		TIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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On this day, March 10, 2025, at 10:45 am, Licensing Program Analyst (LPA) Delmundo conducted an announced pre-licensing inspection and met with Corshema Taylor, applicant-administrator, and Anthony Taylor, applicant. License application is for change of location for four (4) total capacity, all ambulatory. Fire clearance was granted on February 28, 2025.

LPA toured the facility inside out with the applicants. LPA inspected the living room, kitchen, bedrooms, bathrooms, front, side and backyard. Bedrooms were observed appropriately furnished with adequate lighting and drawers. The facility has sufficient towels and linens. Supplies for residents' personal hygiene are available and on site. Dinner and silver wares were observed adequate for residents' use. There’s 7 days supplies of non-perishables and 2 days of perishables. Facility is equipped with refrigerator, microwave and dishwasher. Central storage for medications, cabinet for cleaning supplies and cabinets for residents and staff files were observed with locks. Facility has working land line phone and internet service.

First aid kit inspected and observed complete with manual. Fire extinguisher was observed fully charge with tag showed serviced 12/05/24. Facility has carbon monoxide and smoke detectors that were tested and observed functional. Hot water temperature was tested and measured at 108.6 degrees Fahrenheit.

Applicants currently operates other Adult Residential Facilities (ARFs). Component III training is being waived.

LPA observed the following:
-at 11:22 am, part of the backyard with uneven ground surface.

.....continued on 809C (page 2)
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2025
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 2
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: EMPOWERING VISIONS III
FACILITY NUMBER: 019201531
VISIT DATE: 03/10/2025
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Applicants stated they will have the facility gardener put stones and sand to level the backyard. Picture to be submitted by March 14, 2025.

LPA will inform the Central Application Bureau (CAB) analyst when proof of correction is received. Upon final review of application, license to be granted by CAB analyst.

The following were discussed:
Updating the clients and staff records to reflect the new facility license number.

Exit interview conducted and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2025
LIC809 (FAS) - (06/04)
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