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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200310
Report Date: 02/04/2025
Date Signed: 02/04/2025 02:47:15 PM

Document Has Been Signed on 02/04/2025 02:47 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 PEPPERWOODFACILITY NUMBER:
079200310
ADMINISTRATOR/
DIRECTOR:		DEL ROSARIO, MARKFACILITY TYPE:
735
ADDRESS:109 JUNIPER COURTTELEPHONE:
(925) 768-6177
CITY:HERCULESSTATE: CAZIP CODE:
94547
CAPACITY: 6CENSUS: 6DATE:
02/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:OFELIA LADIAO, CARE GIVER TIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On 2/04/2025 at 1:15 PM, Licensing Program Analyst (LPA) Carol Fowler arrived unannounced to conduct Required 1 Year Annual inspection. LPA met with Caregiver Ofelia Ladiao, and explained the purpose of the visit. Administrator Mark Del Rosario arrived at 2:45PM The facility’s fire clearance was approved for 4 Ambulatory and 2 Non-Ambulatory. Administrator Rhodora Del Rosario arrived at 2:00PM.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 4 total bedrooms which 3 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 73 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 113.5 degree Fahrenheit. All toilets, hand washing stations, and bathing stations are safe, sanitary and in operating condition. The supply of extra hygiene’s were available for clients. There is a minimum of 7 day 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 10/07/2024. Emergency Disaster Drill earthquake and fire drill was last conducted on 1/06/2025. First aid kit was observed to be complete.

Continue on LIC 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
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
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: BUENAVISTA HOME AT PEPPERWOOD
FACILITY NUMBER: 079200310
VISIT DATE: 02/04/2025
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Continue from LIC 809

LPA reviewed 3 client records, and 2 staff records. LPA reviewed a sample of 3 of 6 client medications.

LPA reviewed Updated copies of the following documents.

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


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: 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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