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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601533
Report Date: 05/03/2024
Date Signed: 05/03/2024 04:43:29 PM


Document Has Been Signed on 05/03/2024 04:43 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:CAMELLIA GARDEN IIFACILITY NUMBER:
075601533
ADMINISTRATOR:SAVIDGE, ROSITAFACILITY TYPE:
740
ADDRESS:390 EL DIVISADERO AVENUETELEPHONE:
(925) 457-5942
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:6CENSUS: 5DATE:
05/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator Jingjing Wang CostelloTIME COMPLETED:
05:00 PM
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On 05/03/2024 at 11 am, Licensing Program Analysts (LPAs) J. Sampair and A. Gharachorloo arrived unannounced to conduct the Required Annual Inspection of the facility. Upon arrival, LPAs stated the purpose of the visit to Administrator Jingjing Wang Costello.

LPAs inspected the interior and exterior of the facility, including the kitchen, dining area, restrooms, community living spaces, resident rooms, storage areas, and the grounds of the facility. More than the required minimum of 7 days of nonperishable and 2 days of perishable foods were appropriately stored. Temperature in the living room was measured at 72 degrees Fahrenheit at 2:28 pm. Fire extinguisher was fully charged and last serviced on 02/22/2024.

The carbon monoxide and smoke detector was fully operational. The LPAs observed postings in the facility that included a complaint poster, Ombudsman and Personal Rights posters, Theft and Loss Policy, Rights to Resident Council, and Rights to Family Council.

An administrator is on site more than the minimum of 20 hours a week to oversee the proper business operations. The LPAs reviewed facility records, records of 5 staff members, and records of 5 residents. The LPAs interviewed 2 staff members and 2 residents.

No citations issued during inspection.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 529-9416
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2024
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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