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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200150
Report Date: 02/04/2025
Date Signed: 02/04/2025 12:46:45 PM

Document Has Been Signed on 02/04/2025 12:46 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:APPLETREE ADULT RESIDENTIAL CARE HOMEFACILITY NUMBER:
079200150
ADMINISTRATOR/
DIRECTOR:		NOLITA DAVIDFACILITY TYPE:
735
ADDRESS:2908 SARGENT AVE.TELEPHONE:
(510) 262-0270
CITY:SAN PABLOSTATE: CAZIP CODE:
94806
CAPACITY: 4TOTAL ENROLLED CHILDREN: 0CENSUS: 2DATE:
02/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:NOLITA DAVID, ADMINISTRATORTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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On 02/04/2025 at 10:00 AM, Licensing Program Analyst (LPA) C. Fowler arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Nolita David and explained the purpose of the visit. The facility’s fire clearance was approved for 6 ambulatory clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 3 total bedrooms which 2 bedrooms are occupied by the clients and 1 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 70 degree 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 110.4 degree Fahrenheit. All toilets, hand washing and bathing are safe, sanitary and in operating condition. The supply of extra hygienes were available for clients. There is a minimum of one week supply of non-perishables and 2-day perishables food supply.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 9/27/2024. Emergency Disaster and Fire Drill was last conducted on 2/15/2024. First aid kit was observed to be complete.

LPA reviewed 2 clients records. LPA reviewed 1 staff records and 2 of 2 have current first aid training and associated to the facility. A sample of 2 client’s medications were reviewed.

Continue on LIC809C
Bennett FongTELEPHONE: (510) -62-2621
Carol FowlerTELEPHONE: (510) 622-2715
DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/04/2025
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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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: APPLETREE ADULT RESIDENTIAL CARE HOME
FACILITY NUMBER: 079200150
VISIT DATE: 02/04/2025
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Continue from LIC809

LPA reviewed Updated copies of the following documents.

LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 400 Affidavit Regarding Client/Resident Cash Resources
LIC 402 Surety Bond
LIC 610E Emergency Disaster Plan


No deficiencies were cited during this inspection.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025
LIC809 (FAS) - (06/04)
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