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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601497
Report Date: 05/18/2022
Date Signed: 05/18/2022 04:29:29 PM


Document Has Been Signed on 05/18/2022 04:29 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:AARON'S ADVANCE CARE HOME INC.FACILITY NUMBER:
075601497
ADMINISTRATOR:QUIAMBAO, ROSA ELMAFACILITY TYPE:
740
ADDRESS:122 LOS ALTOS AVENUETELEPHONE:
(925) 954-5329
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:6CENSUS: 3DATE:
05/18/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Rosa QuiambaoTIME COMPLETED:
05:00 PM
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On 5/18/22, Licensing Program Analyst (LPA) J. Sampair conducted an unannounced Proof Of Correction (POC) visit and met with Licensee Rosa Quiambao. LPA explained the purpose of the visit to Licensee.

The Licensee showed the LPA proof of correction for "a written plan to provide emergency power to be self-reliant for the required period of time". However, Licensee was unable to "provide proof of training of CPR certification" because it had not been completed before the LPA's arrival. Because of the failure to complete this correction by the due date, the LPA assessed a $1,300 civil penalty.

The Licensee did complete a CPR course and provide proof of its completion during the visit and the LPA provided her with a proof of correction letter.

Exit interview conducted with Licensee. A copy of report, civil penalty, and appeal rights provided via email..
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2022
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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