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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200616
Report Date: 11/21/2023
Date Signed: 11/21/2023 11:24:36 AM

Document Has Been Signed on 11/21/2023 11:24 AM - 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:LUCCHESI GROUP ADULT RESIDENTIAL CAREFACILITY NUMBER:
079200616
ADMINISTRATOR:VALADEZ, ARMANDOFACILITY TYPE:
735
ADDRESS:4739 LUCCHESI COURTTELEPHONE:
(925) 457-0913
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 4CENSUS: 4DATE:
11/21/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Armando Valdez, AdministratorTIME COMPLETED:
11:35 AM
NARRATIVE
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On 11/21/2023 at 11:05am, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct a Case Management visit. LPA met with Armando Valdez, Administrator and explained the purpose of the visit.

While LPA was conducting a complaint investigation (15-AS-20231115143225) on 11/21/2023. Upon arrival LPA observed construction being conducted. S1 stated that a new additional dwelling with a new address was being built on property. LPA obtain building permit during visit.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2023
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
Document Has Been Signed on 11/21/2023 11:24 AM - It Cannot Be Edited


Created By: Laura Hall On 11/21/2023 at 11:13 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LUCCHESI GROUP ADULT RESIDENTIAL CARE
FACILITY NUMBER: 079200616

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/28/2023
Section Cited
CCR
80086(a)

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80086 Alterations to Existing Building or New Facilities
(a) Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change.
This requirement was not met as evidence by:
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Administrator submitted permit during visit and will contact CAB for further instruction. Deficiency cleared during visit.
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Based on observation the Licensee did not comply with the section cited above in notifying CCLD regarding construction, which poses a possible health and safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2023


LIC809 (FAS) - (06/04)
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