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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601514
Report Date: 05/30/2024
Date Signed: 05/30/2024 01:20:58 PM


Document Has Been Signed on 05/30/2024 01:20 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:PENNY'S GUEST HOMEFACILITY NUMBER:
075601514
ADMINISTRATOR:GARDNER, JOSEFINAFACILITY TYPE:
740
ADDRESS:78 RYEGATE PLACETELEPHONE:
(925) 361-8781
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY:6CENSUS: 5DATE:
05/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Licensee, Josefina GardnerTIME COMPLETED:
01:30 PM
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On 05/30/2024 at 9:50 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct Required 1 Year Annual inspection. Upon arrival LPA was greeted by caregivers. Licensee arrived at 12:14PM. LPA met with Licensee, Josefina Gardner and explained the purpose of the visit. The facility’s fire clearance was approved for 6 Non-Ambulatory.

LPA toured facility with Josefina including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 6 total bedrooms which 5 bedrooms are occupied by the residents and 1 bedroom are occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 69 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathrooms was measured at 111.6 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum 7 day supply of nonperishable and 2 day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents.

Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last purchased on 01/10/2024. Emergency Disaster plan last reviewed 5/30/2024.

At 10:30 AM, LPA reviewed 5 of 5 residents records. At 11:20 AM, LPA reviewed 3 staff records and 3 of 3 have first aid training and are associated to the facility. At 12:00 PM, LPA reviewed a sample of resident’s medications.


No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2024
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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