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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601221
Report Date: 01/17/2025
Date Signed: 01/17/2025 04:06:09 PM

Document Has Been Signed on 01/17/2025 04:06 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:LARKEY PARK HOME CAREFACILITY NUMBER:
075601221
ADMINISTRATOR/
DIRECTOR:		CAMACLANG, ALBERTINA RFACILITY TYPE:
740
ADDRESS:2532 LARKEY LANETELEPHONE:
(925) 287-8590
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94597
CAPACITY: 6CENSUS: 5DATE:
01/17/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:20 PM
MET WITH:Tina Camaclang, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:10 PM
NARRATIVE
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On 01/17/2025 at 12:20 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a Case Management regarding discussion pertaining to alterations to the garage. LPA met with Caregiver, Jenny Laguna, and explained the reason for visit. Jenny phoned, Administrator, Tina Camaclang to inform. Tina Camaclang arrived approximately 15 mins later.

During an annual visit on 12/03/2024, LPA observed residents occupying bedroom #5, #6 and that the detached two-car garage had been modified. LPA spoke with Administrator and Administrator stated that the outside garage that appears like a cottage today was like that for years and used for storage. LPA reviewed the facility sketch from the office file (dated 2005) and the rooms were labeled Staff Bedroom and Office where the residents were residing. LPA spoke with Administrator on 01/10/2025 to clarify if there were modifications to the detached garage. The Administrator stated not having any knowledge of garage modifications. The Administrator stated that they didn't have the keys to open the door so that LPA could tour the space. LPA observed that one (1) resident was moved to a different bedroom.

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided.


SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2025
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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Document Has Been Signed on 01/17/2025 04:06 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 01/17/2025 at 01:13 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LARKEY PARK HOME CARE
FACILITY NUMBER: 075601221

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/31/2025
Section Cited
CCR
87305(a)

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87305 Alterations to Existing Building or New Facilities (a) Prior to construction or alterations, all facilities shall obtain a building permit.

This requirement is not met as evidenced by:
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Administrator agreed to submit a copy of building permit for modified garage and updated facility sketch.
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Based on observation and interview the licensee did not comply with the section cited above in by not having a building permit for modifications to the detached garage which poses a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bennett Fong
LICENSING EVALUATOR NAME:Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2025


LIC809 (FAS) - (06/04)
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