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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200586
Report Date: 09/04/2024
Date Signed: 09/04/2024 03:35:55 PM


Document Has Been Signed on 09/04/2024 03:35 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:FITZPATRICK HILLS MANOR LLCFACILITY NUMBER:
079200586
ADMINISTRATOR:FERNANDEZ,MARIETTAFACILITY TYPE:
735
ADDRESS:2468 FITZPATRICK STREETTELEPHONE:
(510) 862-7199
CITY:SAN PABLOSTATE: CAZIP CODE:
94806
CAPACITY:6CENSUS: 4DATE:
09/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:ASHLEY FERNANDEZ, ADMINISTRATORTIME COMPLETED:
04:07 PM
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On 9/4/2024 at 01:30PM, Licensing Program Analyst (LPA) Carol Fowler conducted an unannounced 1-Year Required inspection. LPA met with Administrator, Ashley Fernandez and explained the purpose of the visit. The Administrator currently holds a certificate (#6027553735) that expired on 09/15/2025. The facility’s fire clearance was approved for six (6) ambulatory residents.

LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of three (3) total bedrooms. There are three (2) full bathrooms. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature is maintained at 70 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Hot water temperature in the shared clients’ bathroom was measured at 99.9 degrees Fahrenheit. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 11/6/2023. Emergency Disaster Plan was last posted on 04/22/2024. First aid kit was observed to be complete. Fire drill was last conducted on 05/02/2024.

Continued on LIC809C
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/04/2024
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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: FITZPATRICK HILLS MANOR LLC
FACILITY NUMBER: 079200586
VISIT DATE: 09/04/2024
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Continued from LIC809

Five (5) staff records were reviewed, and all staff have criminal record clearance and holds a current first aid/CPR certificate. three (3) Clients records were reviewed all complete.

LPA requested the following documents to be submitted to CCLD by 09/12/2024.

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


Exit interview conducted. A copy of appeal rights and this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024
LIC809 (FAS) - (06/04)
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