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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200308
Report Date: 12/18/2023
Date Signed: 12/18/2023 10:59:05 AM

Document Has Been Signed on 12/18/2023 10:59 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:SHIRLEY'S CARE HOMEFACILITY NUMBER:
079200308
ADMINISTRATOR:JONES, SHIRLEYFACILITY TYPE:
735
ADDRESS:203 JOAQUIN DRIVETELEPHONE:
(925) 806-0515
CITY:DANVILLESTATE: CAZIP CODE:
94526
CAPACITY: 6CENSUS: 4DATE:
12/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator, Shirley JonesTIME COMPLETED:
11:15 AM
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At 9:00am, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct an Annual Inspection on this date. LPA was greeted by Staff, Rossie Foster. Administrator, Shirley Jones later arrived at 9:30am. The facility's fire clearance was approved for all may be ambulatory only.

LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. 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 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 114.1 degrees Fahrenheit. All toilets, hand washing and bathing are safe, sanitary and in operating condition. The supply of extra hygiene were available for clients. There is a minimum of 7-day nonperishable and 2-day perishable foods.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 8/14/2023 . First aid was observed to be complete. Fire drill was last conducted on 12/09/2023 .

LPA reviewed 4 staff records and 4 of 4 staff have current first aid training and are associated to the facility. LPA reviewed 4 clients records and a sample of clients medications. Clients were away at day program. Staff left once administrator arrived.

Report continues on LIC 809-C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE: DATE: 12/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2023
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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: SHIRLEY'S CARE HOME
FACILITY NUMBER: 079200308
VISIT DATE: 12/18/2023
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The following forms to be updated and submitted to CCLD 12/31/2023:

LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 400 Affidavit Regarding Client/Resident Cash Resources
LIC 402 Surety Bond
LIC 610D Emergency Disaster Plan
Liability Insurance
Lease Agreement
Administrator's Certificate

No deficiencies were cited during this inspection. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2023
LIC809 (FAS) - (06/04)
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