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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200037
Report Date: 11/30/2022
Date Signed: 11/30/2022 01:32:57 PM

Document Has Been Signed on 11/30/2022 01:32 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:RESIDENTIAL & EDUCATIONAL SERVICESFACILITY NUMBER:
079200037
ADMINISTRATOR:IAN BREMNERFACILITY TYPE:
775
ADDRESS:620 LAS JUNTASTELEPHONE:
(925) 957-1665
CITY:MARTINEZSTATE: CAZIP CODE:
94553
CAPACITY: 20CENSUS: 8DATE:
11/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:44 PM
MET WITH:Kristina Sharkey, DSPTIME COMPLETED:
01:40 PM
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On 11/30/22 at 12:44 PM, Licensing Program Analysts (LPAs) L. Alexander and C. Fowler arrived unannounced to conduct 1-Year Annual Required inspection. We we're greeted by Staff, Vanessa Lopez and Kristina Sharkey, DSPs. LPAs met with Program Director, Nicole Doubley and explained the purpose of the visit. Day program operates from 10:00 AM to 2:00 PM. There were 3 staff observed working with the 8 participants here today.

LPAs toured facility with Kristina Sharkey including but not limited to, multiple activity rooms, kitchen, bathrooms, and office space. Clients bring their own lunches and snacks. Emergency supplies, including water were observed. Cleaning supplies are locked and inaccessible to clients. Medications are not handled/dispensed by this program. There are no bodies of water or fire safety hazards observed. Restrooms are maintained in safe and in sanitary operating condition, and additional equipment for the physically handicapped was observed.

Fire extinguishers throughout facility were last inspected June 2022. First aid kit was checked.

The following forms to be updated and submitted to CCL by 12/7/2022:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 610 Emergency Disaster Plan

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2022
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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