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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200630
Report Date: 12/27/2022
Date Signed: 12/27/2022 07:07:45 PM

Document Has Been Signed on 12/27/2022 07:07 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:BYRON PARKFACILITY NUMBER:
079200630
ADMINISTRATOR:JENNIFER MURRAY PASTORAFACILITY TYPE:
740
ADDRESS:1700 TICE VALLEY BLVDTELEPHONE:
(925) 937-1700
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94595
CAPACITY: 151CENSUS: 88DATE:
12/27/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
06:00 PM
MET WITH:Gia AronTIME COMPLETED:
07:30 PM
NARRATIVE
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On 12/27/2022, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to conduct a change of ownership prelicensing visit for Byron Park #079201218. LPA met with Resident Relations Director Gia Aron and informed her of the reason for the visit.

During the visit, the LPA issued one citation (LIC 809-D) under this existing license.

Exit interview conducted and a copy of this report provided via email.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 12/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2022
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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Document Has Been Signed on 12/27/2022 07:07 PM - It Cannot Be Edited


Created By: James Sampair On 12/27/2022 at 05:36 PM
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: BYRON PARK
FACILITY NUMBER: 079200630

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/17/2023
Section Cited

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87203 Fire Safety
All facilities shall be maintained in conformity with the regulations adopted by the State Fire
Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
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Based on observation, the licensee did not comply with the section cited above by not completing the service of all fire extinguishers annually as per Title 19 Section 575.1 - Maintenance and
Required Service Intervals, which poses a potential health, safety or personal rights 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:James Sampair
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2022


LIC809 (FAS) - (06/04)
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