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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200205
Report Date: 06/02/2022
Date Signed: 06/02/2022 02:21:44 PM

Document Has Been Signed on 06/02/2022 02:21 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 1FACILITY NUMBER:
079200205
ADMINISTRATOR:RUFFY B. YUFACILITY TYPE:
735
ADDRESS:47 BIGELOW PLACETELEPHONE:
(925) 361-5285
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY: 6CENSUS: 5DATE:
06/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Laurina Garcia, Care StaffTIME COMPLETED:
02:30 PM
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On 6/2/2022 at 1:40 PM, Licensing Program Analyst (LPAs) L. Francisco and K. Nguyen arrived unannounced to conduct Infection Control Inspection. LPAs met with Care Staff, Laurina Garcia and explained the purpose of the visit.

During the Infection Control Inspection, LPAS toured facility with Care Staff including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and backyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Hand washing posters were observed. Common touched surfaces are disinfected at least once daily. Bathrooms are equipped with liquid soap and paper towel. Facility staff were observed to be wearing proper PPE. PPEs are maintained at central location and easily accessible for staff.

At 2:05 PM, LPAs reviewed 3 staff records and 3 of 3 have health screening and TB test on file. Facility has a mitigation on file.



REPORT CONTINUES ON 809C
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Lizette Francisco
LICENSING EVALUATOR SIGNATURE: DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/02/2022
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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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 RESIDENTIAL CARE 1
FACILITY NUMBER: 079200205
VISIT DATE: 06/02/2022
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Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 6/6/2022:
  • 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 610D Emergency Disaster Plan
  • Administrator's Certificate
  • Liability Insurance


No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Lizette Francisco
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022
LIC809 (FAS) - (06/04)
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