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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601447
Report Date: 11/10/2021
Date Signed: 11/10/2021 10:27:11 AM

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:LAFAYETTE RESIDENTIAL CAREFACILITY NUMBER:
075601447
ADMINISTRATOR:OPHELIA PEDROSOFACILITY TYPE:
740
ADDRESS:1300 JUANITA DRIVETELEPHONE:
(925) 945-6833
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94595
CAPACITY:6CENSUS: DATE:
11/10/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:51 AM
MET WITH:Ophelia Pedroso, AdministratorTIME COMPLETED:
10:30 AM
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On 11/10/2021 at 09:30AM, Licensing Program Analysts (LPAs), L. Hall and J. Clancy-Czuleger arrived to conducted a follow-up Plan of Correction visit regarding citations issued on 10/21/2021. LPAs met with Ophelia Pedroso, Administrator and explained the reason for the visit.

POC visit is regarding verifying fence is built around pond in backyard and CCR 87705 (e) that was cited during an complaint investigation visit on 10/21/2021. LPA Hall did not receive POC for CCR 87705(e) by POC due date; which was 11/04/2021. During POC visit, LPAs observed fence partially completed. A civil penalty of $600 is assessed for failure to correct for CCR 87705(e) by POC date; $100 per day from 11/05/2021 to 11/10/2021.



Exit interview was conducted and a copy of report along with appeal rights and LIC421FC was given.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021
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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