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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601538
Report Date: 06/16/2021
Date Signed: 06/16/2021 02:41:26 PM

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 IIIFACILITY NUMBER:
075601538
ADMINISTRATOR:GRUTAS, JAYFACILITY TYPE:
740
ADDRESS:2374 WARREN ROADTELEPHONE:
(925) 938-0200
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94595
CAPACITY:6CENSUS: 6DATE:
06/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Katherine Grutas, AdministratorTIME COMPLETED:
02:45 PM
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On 6/16/2021 at 02:25PM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Infection Control Inspection. LPA met with Katherine Grutas, Administrator . and explained the purpose of the visit.

Main entry is located at 2380 Warren Rd. The facilities are connected by using the backyard. Before entering LPA observed a sign to stop visitors. There is a bell for visitors to ring for staff. Staff conducts screening with a tablet and takes temperature. Upon entering there is a cart that contains and hand sanitizer and other PPE. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, backyard. All hand washing stations were equipped with soap, paper towel, and hand washing posters were posted.

During record review, LPA observed facility has a copy of Mitigation Plan on file. LPA observed PPE, food, and paper supplies are sufficient.

No deficiencies were cited during this inspection.

Exit interview conducted. A copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021
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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