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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601180
Report Date: 04/09/2024
Date Signed: 04/09/2024 04:35:34 PM


Document Has Been Signed on 04/09/2024 04:35 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:WELCOME HOME SENIOR RESIDENCE (WALNUT CREEK)FACILITY NUMBER:
075601180
ADMINISTRATOR:CHOU, STEVEFACILITY TYPE:
740
ADDRESS:2421 WASDEN COURTTELEPHONE:
(925) 944-0204
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:6CENSUS: 6DATE:
04/09/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Licensee Steve ChouTIME COMPLETED:
04:45 PM
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On 4/9/2024 at 3:15 PM, Licensing Program Analyst (LPA) J. Sampair arrived at facility unannounced to conduct this case management visit. Upon arrival, the LPA stated the purpose of the visit to Licensee Steve Chou, which was to verify the health and safety of their new resident who was admitted on 4/6/2024 due to the fire at Casa Blanca Homes (071441125).

At 3:15 PM, the LPA observed Resident R1 in their room. They were safe and healthy in their bed. The Licensee stated that the last of their belongings were brought only an hour earlier.

No citations issued during this visit.

Exit interview conducted with Caregiver Rio Clark and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 529-9416
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2024
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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