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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600757
Report Date: 04/21/2021
Date Signed: 04/21/2021 12:18:10 PM

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:FAMILY COURTYARDFACILITY NUMBER:
075600757
ADMINISTRATOR:TEJERO, NORMAFACILITY TYPE:
740
ADDRESS:2840 SALESIAN AVENUETELEPHONE:
(510) 235-8284
CITY:RICHMONDSTATE: CAZIP CODE:
94804
CAPACITY:70CENSUS: 46DATE:
04/21/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Norma TejeroTIME COMPLETED:
10:55 AM
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On this day, Licensing Program Analyst (LPA) conducted a case management televisit and met with Administrator Norma Tejero. LPA explained to the Administrator that this visit is being conducted via Zoom in connection with the telework directive by management.

This visit is in connection with the two death reports received by Community Care Licensing (CCL). LPA requested that the following records for Resident 1 (R1) and Resident 2 (R2) be sent to LPA:

1. Physician's Report
2. Needs and Services Plan
3. caregiver notes for April 2021
4. death certificates

LPA advised Administrator to request death certificates for R1 and R2 and send to CCL.

A copy of this report will be sent to Administrator via email.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2021
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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