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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200239
Report Date: 12/09/2022
Date Signed: 12/09/2022 11:25:32 AM

Document Has Been Signed on 12/09/2022 11:25 AM - 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:RES SUCCESSFACILITY NUMBER:
079200239
ADMINISTRATOR:IAN BREMNERFACILITY TYPE:
775
ADDRESS:702 ALFRED NOBEL DR.TELEPHONE:
(925) 229-8228
CITY:HERCULESSTATE: CAZIP CODE:
94547
CAPACITY: 30CENSUS: 13DATE:
12/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:JOHANNA GALVAN PROGRAM MANAGERTIME COMPLETED:
11:40 AM
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Licensing Program Analyst (LPA) Carol Fowler arrived for an unannounced to conduct an infection control inspection. LPA met with Program Director, Johanna Galvan. Facility operates between the hours of 8:30am- 2:00pm. There were 6 staff observed working with 13 participants here today.

LPA toured facility with Program Director, Johanna including but not limited to activity room, common areas, kitchen and bathrooms.. The facility does not provide lunch but has an area/refrigerator where clients can place their items they receive from home. Medications are not handled/dispensed by this program. Sharps and chemicals were observed to be locked in a closet and in Program Managers office. First aid kit checked and complete. Smoke detector and carbon monoxide observed and are operational. Fire extinguisher checked and last serviced on 11/2/2022.



No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2022
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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