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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200030
Report Date: 12/29/2021
Date Signed: 12/29/2021 02:25:08 PM

Document Has Been Signed on 12/29/2021 02:25 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:CROW CANYON RESIDENTIAL CARE IVFACILITY NUMBER:
079200030
ADMINISTRATOR:RUFFY B. YUFACILITY TYPE:
735
ADDRESS:1385 JENSEN DRIVETELEPHONE:
(925) 432-8786
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY: 6CENSUS: 5DATE:
12/29/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Ruffy Yu, AdministratorTIME COMPLETED:
02:40 PM
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On 12/29/21 at 2:15PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted a Health and Safety check as a result of the department receiving a priority 1 complaint.

During the health and safety check, LPA observed a total of 2 staff members wearing face masks assisting 5 clients resting in their bedrooms during visit. LPA toured facility with staff (S1) including but not limited to bedrooms, kitchen, bathroom, and common areas. Clients in care appear to be safe and there are no imminent health/safety concerns on today's date.

No deficiencies cited during the health and safety check. Exit interview conducted and a copy of this report provided via email.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 12/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/29/2021
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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