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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200616
Report Date: 08/28/2024
Date Signed: 08/28/2024 01:34:13 PM

Document Has Been Signed on 08/28/2024 01:34 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:LUCCHESI GROUP ADULT RESIDENTIAL CAREFACILITY NUMBER:
079200616
ADMINISTRATOR/
DIRECTOR:		VALADEZ, ARMANDOFACILITY TYPE:
735
ADDRESS:4739 LUCCHESI COURTTELEPHONE:
(925) 457-0913
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 4CENSUS: 4DATE:
08/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:11 AM
MET WITH:Maria Gonzalez Del Rio, LicenseeTIME VISIT/
INSPECTION COMPLETED:
01:56 PM
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On 08/28/2024 at 11:11am, Licensing Program Analyst (LPA) T. Syess-Gibson conducted an unannounced annual 1-Year required inspection. LPA met with Maria Gonzalez Del Rio, Licensee, and explained the purpose of the visit. Maria contacted Administrator, Armando Valadez via telephone. Administrator, Armando Valadez, arrived at 11:36am. The administrator currently holds a certificate (#6040505735) that expires on 11/10/2024. The facility’s fire clearance was approved for six (6) ambulatory clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, garage, and back yard. The facility consists of four (4) total bedrooms and two (2) bathrooms. All indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 75 degrees Fahrenheit. LPA 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 109.7 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 and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 06/14/2024. Emergency Disaster Plan was last posted on 03/25/2024. Fire drill last conducted on 05/15/2024. First aid kit was observed to be complete.

Continued LIC809C

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2024
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: LUCCHESI GROUP ADULT RESIDENTIAL CARE
FACILITY NUMBER: 079200616
VISIT DATE: 08/28/2024
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Continued from LIC809.

Four (4) staff records were reviewed, and all staff have first aid certification. All four (4) clients' records reviewed, current, and complete. LPA reviewed facility Van (transportation) service invoices and registration during visit. LPA also reviewed P&I and a sample of medication.


The following forms to be updated and submitted to CCLD by 09/04/2024:

· Liability insurance
· Surety Bond
· LIC500 (Personnel Record)
· LIC 9020 (Client Roster)
· LIC308 (Designation of facility Responsibility)
· LIC400 (Affidavit Regarding Client/Resident Cash Resources)
· LIC610D (Emergency Disaster Plan)

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: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024
LIC809 (FAS) - (06/04)
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