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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200326
Report Date: 02/11/2025
Date Signed: 02/11/2025 12:35:38 PM

Document Has Been Signed on 02/11/2025 12:35 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:ATRIA PARK OF LAFAYETTEFACILITY NUMBER:
079200326
ADMINISTRATOR/
DIRECTOR:		ANTHONY, KAWANAFACILITY TYPE:
740
ADDRESS:1545 PLEASANT HILL RDTELEPHONE:
(925) 932-9910
CITY:LAFAYETTESTATE: CAZIP CODE:
94549
CAPACITY: 130TOTAL ENROLLED CHILDREN: 0CENSUS: 81DATE:
02/11/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Resident Services Director Beverly MercurioTIME VISIT/
INSPECTION COMPLETED:
12:50 PM
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On 02/11/2025 at 09:00 AM, Licensing Program Analyst (LPA) D. Doidge arrived unannounced to conduct an annual required inspection. LPA met with Resident Services Director Beverly Mercurio and explained the purpose of the visit.

LPA toured the facility including but not limit to, bedrooms, bathrooms, multiple activity rooms, kitchen, outside, and common areas. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 72 degrees Fahrenheit. The hot water temperature is controlled in a common boiler room. The temperature is set to 112.3 degrees Fahrenheit. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps are locked and inaccessible to residents in care.

Fire extinguisher was last serviced on 06/21/2024. Emergency disaster drill are conducted quarterly. Last drill conducted on 12/01/2024.

LPA reviewed five (5) resident records and five (5) staff records, all were complete.

Continued on LIC809-C
Bennett FongTELEPHONE: (510) 286-4201
David DoidgeTELEPHONE: (916) 475-5913
DATE: 02/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/11/2025
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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ATRIA PARK OF LAFAYETTE
FACILITY NUMBER: 079200326
VISIT DATE: 02/11/2025
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Continued from LIC809

LPA requested the following documents to be submitted to CCLD by 02/18/2025.

· LIC 308 Designation of Administrative Responsibility
· LIC 309 Administrative Organization
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan
· Liability Insurance

No deficiencies observed or cited during this visit. .

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 286-4201
LICENSING EVALUATOR NAME: David DoidgeTELEPHONE: (916) 475-5913
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2025
LIC809 (FAS) - (06/04)
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