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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600294
Report Date: 08/18/2022
Date Signed: 08/18/2022 05:02:09 PM


Document Has Been Signed on 08/18/2022 05:02 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:ABRAHAM REST HOMEFACILITY NUMBER:
075600294
ADMINISTRATOR:SANCHEZ, ALEXFACILITY TYPE:
740
ADDRESS:1095 BANCROFT COURTTELEPHONE:
(925) 945-7398
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:6CENSUS: 5DATE:
08/18/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Annette SanchezTIME COMPLETED:
05:30 PM
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On 8/18/22 at 1:30 PM, Licensing Program Analyst (LPA) J. Sampair conducted a facility visit concerning a hospice waiver for an existing resident, R1, and an additional structure not on the original facility sketch. Upon arrival, LPA informed staff members S2 and S3 of the purpose of the visit. The staff contacted Annette Sanchez, who arrived shortly thereafter and met with LPA.

Ms. Sanchez stated that R1 had died the day before, so the increase in their hospice waiver from 1 to 3 was no longer urgent. Before Ms. Sanchez arrived, staff member S3 showed the LPA where workers were in the process of taking the structure down. At the time the LPA saw the structure, the workers were in the process of removing the floorboards, removing the concern the LPA had about the facility sketch not being accurate.

No deficiencies were issued. An exit interview was conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2022
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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