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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200334
Report Date: 10/21/2020
Date Signed: 12/04/2020 03:05:12 PM

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:AMAZING HOME CARE IIFACILITY NUMBER:
079200334
ADMINISTRATOR:MARILOU SOLOMONFACILITY TYPE:
740
ADDRESS:5017 SAINT GARRETT COURTTELEPHONE:
(925) 671-7909
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY:6CENSUS: 4DATE:
10/21/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:34 PM
MET WITH:Almarie SolomonTIME COMPLETED:
02:46 PM
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On 10/21/2020 at 2:34PM, Licensing Program Analyst (LPA) Jacob Williams conducted an unannounced Health & Welfare Visit meeting with S1. Due to the state's current shelter in place order, this visit was conducted by tele-video.

LPA toured the home and found there to be a sufficient 2 day supply of perishable foods and 7 day supply of non-perishable foods for the 4 residents. LPA found the water to be running and all sinks and toilets functional. LPA observed no trash build up. LPA observed electricity and gas are on. S1 indicated that the current census was 4 and LPA observed all residents to look well-kept. LPA observed the residents to have no obvious marks or bruising and were adequately groomed and attired. Residents were in no obvious distress.

Exit interview conducted and copy emailed out.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Jacob WilliamsTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2020
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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