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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200317
Report Date: 03/26/2024
Date Signed: 03/26/2024 02:06:47 PM

Document Has Been Signed on 03/26/2024 02:06 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:QUAIL GLEN ADULT RESIDENTIAL FACILITY INC.FACILITY NUMBER:
079200317
ADMINISTRATOR:BELINDA CONYERSFACILITY TYPE:
735
ADDRESS:17 BOBWHITE CT.TELEPHONE:
(925) 679-0515
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 6CENSUS: 2DATE:
03/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Belinda Conyers AdministratorTIME COMPLETED:
02:15 PM
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On 03/26/2024 at 11:55am, Licensing Program Analysts (LPA's) T. Syess-Gibson and L. Hall conducted an unannounced annual 1-year required inspection. LPAs met with Belinda Conyers, Administrator, and explained the purpose of the visit. The administrator currently holds a certificate (#6015230735) that expires on 05/29/2024. The facility’s fire clearance was approved for one(1) ambulatory and five (5) non ambulatory clients.

LPAs toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and garage. LPAs toured the backyard which has a swimming pool that is locked and fenced. The facility consists of five (5) total bedrooms and three (3 ) bathrooms. One (1) bedroom used by staff. All indoor passageways are kept free of obstruction. A comfortable temperature for clients is maintained at 72 degrees Fahrenheit. LPAs 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 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Paper towel, and soap observed at all hand washing stations. The supply of extra hygiene was available for residents. There is a minimum of 7-day non-perishables and 2-day perishables foods.

Smoke detectors/carbon monoxide were in operating condition during visit. Fire extinguisher was last purchased on 09/14/2023. Fire drill last conducted 01/28/2024. First aid kit was observed to be complete.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 03/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/26/2024
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 2
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: QUAIL GLEN ADULT RESIDENTIAL FACILITY INC.
FACILITY NUMBER: 079200317
VISIT DATE: 03/26/2024
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Continued from LIC809.

Three (3) staff records were reviewed, and all staff have first aid certification. All two (2) clients' records reviewed, current, and complete. Medications and P&I were also checked.

The following forms to be updated and submitted to CCLD by 04/02/2024
  • Liability insurance.
  • Surety Bond
  • LIC610D (Last Page)
  • LIC308 (Designation of facility Responsibility)
  • LIC400 Affidavit Regarding Client/Resident Cash Resources


No deficiencies cited during visit.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024
LIC809 (FAS) - (06/04)
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