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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601509
Report Date: 02/12/2025
Date Signed: 02/12/2025 01:44:11 PM

Document Has Been Signed on 02/12/2025 01:44 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:MORAGA RETREAT CARE ON WOODFORDFACILITY NUMBER:
075601509
ADMINISTRATOR/
DIRECTOR:		BLAJ, ANAMARIAFACILITY TYPE:
740
ADDRESS:3 WOODFORD DRIVETELEPHONE:
(925) 376-2273
CITY:MORAGASTATE: CAZIP CODE:
94556
CAPACITY: 6CENSUS: 4DATE:
02/12/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:20 PM
MET WITH:Ana Maria Blaj, Administrator TIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On 02/12/2025 at 12:20 PM, Licensing Program Analyst (LPA) David Doidge arrived to conduct 1-Year Annual Required inspection. LPA met with staff Donna Marie Vernon. and explained the purpose of the visit. The Administrator, Ana Maria Blaj, arrived at the facility at around 12:30 PM.

During the visit, LPA toured facility including but not limited to the kitchen, dining room, resident bedrooms and bathrooms, front and back area of the facility, and common areas. Fire extinguisher was observed full and last inspected on 04/16/2024. Smoke detectors and carbon monoxide detectors were tested and observed functional. LPA observed the facility to be at a comfortable temperature for residents. All indoor and outdoor passageways are kept free of obstruction. Hot water temperature was measured at XXX degrees Fahrenheit. LPA observed skid mats and grab bars in resident bathrooms. LPA observed sufficient furniture and lighting throughout the facility. There are no bodies of water present in or around the facility. LPA observed a sufficient supply of 7 day non-perishables and two day perishable food supplies.

LPA reviewed four (4) resident files and two (2) staff files. The last fire and earthquake drills were conducted on 12/10/2024. Centrally stored medications were observed locked in a cabinet.

Continued on LIC 809-C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: David Doidge
LICENSING EVALUATOR SIGNATURE: DATE: 02/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/12/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: MORAGA RETREAT CARE ON WOODFORD
FACILITY NUMBER: 075601509
VISIT DATE: 02/12/2025
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Continue from LIC 809

LPA requested the following documents to be submitted to CCLD by 2/19/2025.

· Resident Roster
· LIC 308 Designation of Administrative Responsibility
· LIC 309 Administrative Organization
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan (9 pages)
· Liability Insurance

No deficiencies observed or cited during this visit. .

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: David Doidge
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025
LIC809 (FAS) - (06/04)
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