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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600354
Report Date: 08/10/2022
Date Signed: 08/10/2022 11:30:37 AM


Document Has Been Signed on 08/10/2022 11:30 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:PENNY'S GUEST HOMEFACILITY NUMBER:
075600354
ADMINISTRATOR:EPIFANIA ANGECIAFACILITY TYPE:
740
ADDRESS:1760 AYERS ROADTELEPHONE:
(925) 330-3086
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY:6CENSUS: 2DATE:
08/10/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:42 AM
MET WITH:Penny Gardner, LicenseeTIME COMPLETED:
11:45 AM
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On 08/10/2022 at 10:42 AM Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to conduct a Case Management. LPA met with Penny Gardner, Licensee.

LPA observed that the floor plan that was submitted to the fire department and to CCLD is accurate. The facility has three additional bedrooms at the back of the house. The fire clearance is for 6 total capacity, of which 6 maybe non-ambulatory. Fire clearance was granted on August 8, 2022.

Exit interview conducted and a copy of report was provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2022
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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