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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200132
Report Date: 08/20/2024
Date Signed: 08/20/2024 12:35:19 PM

Document Has Been Signed on 08/20/2024 12:35 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 CARE HOMEFACILITY NUMBER:
079200132
ADMINISTRATOR/
DIRECTOR:		LINDA PENANOFACILITY TYPE:
735
ADDRESS:47 OXFORD COURTTELEPHONE:
(925) 427-6925
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY: 6CENSUS: 6DATE:
08/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Suarte Joeycelyn Sawyer, House ManagerTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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On 8/20/2024 at 10:00am, Licensing Program Analyst (LPA) L. Hall conducted an unannounced annual required inspection. LPA met with Suarte Joeycelyn Sawyer, House Manager, and explained the purpose of the visit. The Administrator is out-of the country. The backup Administrator, Frank Rodriguez, arrived at 11:30am. The administrator currently holds a certificate (#7033459735) that expires on 11/26/2024. The facility’s fire clearance was approved for six (6) ambulatory clients. All clients were attending the day program during inspection.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of four (4) bedrooms and two (2) bathrooms. One (1) bedroom occupied by staff. All indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 75 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 114.3 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Bathrooms were equipped with non skid mats. Hand washing poster, paper towel, and soap observed at all hand washing stations. The supply of extra hygiene was available for residents. There is a minimum of 7-day non-perishables and 2-day perishables foods.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: CROW CANYON CARE HOME
FACILITY NUMBER: 079200132
VISIT DATE: 08/20/2024
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Continued from LIC809.

Smoke detectors/carbon monoxide were in operating condition during visit. Fire extinguisher last serviced on 05/1/2024. Fire drill last conducted 7/6/2024. First aid kit was observed to be complete.

Five (5) staff records were reviewed and six (6) client records reviewed and all are current. LPA also reviewed P&I.

The following forms to be updated and submitted to CCLD by 8/27/2024:
  • LIC 400 Affidavit Regarding Client/Resident Cash Resources
  • LIC 402 Surety Bond
  • LIC 610D Emergency disaster plan (last page)
  • LIC500 (Personnel Record)


No deficiencies cited during visit.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024
LIC809 (FAS) - (06/04)
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