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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601536
Report Date: 01/27/2023
Date Signed: 01/27/2023 12:33:52 PM


Document Has Been Signed on 01/27/2023 12:33 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:CARNELIAN IFACILITY NUMBER:
075601536
ADMINISTRATOR:GRUTAS, KATHERINEFACILITY TYPE:
740
ADDRESS:2380 WARREN ROADTELEPHONE:
(925) 938-0200
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94595
CAPACITY:15CENSUS: 15DATE:
01/27/2023
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Katherine GruitasTIME COMPLETED:
12:45 PM
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On 01/27/2023 at 11:45 AM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to verify that antigen testing had been conducted as per the request of Contra Costa Health Services. Upon entry into the facility, the LPA identified himself and the purpose of the visit to the Administrator, Katherine Gruitas.

The Administrator and LPA met. During the meeting, the Administrator verified that the COVID-19 antigen testing had been completed for all staff members present in the facility during the time the COVID-19 infected employee was present.

No citations were issued.

Exit interview conducted and a copy of this report provided via email.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2023
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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