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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600757
Report Date: 12/18/2023
Date Signed: 12/18/2023 04:07:37 PM


Document Has Been Signed on 12/18/2023 04:07 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:FAMILY COURTYARDFACILITY NUMBER:
075600757
ADMINISTRATOR:TEJERO, NORMAFACILITY TYPE:
740
ADDRESS:2840 SALESIAN AVENUETELEPHONE:
(510) 235-8284
CITY:RICHMONDSTATE: CAZIP CODE:
94804
CAPACITY:70CENSUS: 42DATE:
12/18/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Jiena Guam, Med techTIME COMPLETED:
04:15 PM
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On 12/18/2023 at 3:10pm, Licensing Program Analyst (LPAs) L. Hall, C. Fowler, and T. Syess-Gibson arrived unannounced to conduct proof of correction (POC) visit. LPA met with Jiena Guam, Med tech and explained the purpose of the visit. Administrator, Norma Tejero, arrived at 3:50pm.

LPA conducted an annual visit on 12/1/2023 and cited facility for the following:

  • 87203 Fire Safety - locks on exit gate - LPA received photo with locks removed on 12/4/2023. LPAs check gates on today's date and did not observe any locks.
  • 87555 General Food Service Requirements - Food - LPA received receipts on 12/12/2023. LPAs observed 7-day perishable foods.
  • 87465 Incidental Medical and Dental Care - first aid kit -LPA received receipt on 12/12/2023 with first aid kit and Band-Aids.
  • 87307 Personal Accommodations and Services - obstructions in passageway - LPA received photo with items removed from passageway.

No deficiencies cited during visit.

Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 12/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2023
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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