<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200260
Report Date: 02/14/2024
Date Signed: 02/14/2024 04:18:56 PM

Document Has Been Signed on 02/14/2024 04:18 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:BUENAVISTA HOME AT PINOLE VALLEYFACILITY NUMBER:
079200260
ADMINISTRATOR:PEREZ, RONALDOFACILITY TYPE:
735
ADDRESS:3799 PINOLE VALLEY ROADTELEPHONE:
(510) 223-0880
CITY:PINOLESTATE: CAZIP CODE:
94564
CAPACITY: 6CENSUS: 4DATE:
02/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Jober Galara, CaregiverTIME COMPLETED:
04:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 2/14/2024 Licensing Program Analysts (LPAs) Carol Fowler and Tonica Syess-Gibson conducted an unannounced required 1 year inspection. LPAs met with Caregiver, Jober Galara. Administrator Ronaldo Perez arrived at 3:50PM.

LPAs toured the facility including but not limited to four (4) bedrooms, two (2) bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water present at this facility. 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 120.0 degrees F. All toilets, hand washing and bathing are safe, sanitary and in operating condition. The supply of extra hygiene were available for clients. Fire extinguisher last serviced on 1/11/2024. Disaster drill last conducted 1/08/2024. First aid kit inspected and complete. Emergency disaster plan posted and dated 12/18/2023.

Four (4) client records were reviewed. All clients had a current needs and service plan, admissions agreement, and medical assessment on file. Four (4) staff records reviewed. All staff were fingerprint cleared and associated to the facility. Staff reviewed had current first aid/ CPR and in good health to perform job functions. P&I reviewed for four (4) clients. P&I was intact and not commingled with facility funds.

No deficiencies, exit interview conducted. A copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2024
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 1