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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200630
Report Date: 01/10/2023
Date Signed: 01/10/2023 05:04:19 PM


Document Has Been Signed on 01/10/2023 05:04 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:
01/10/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Danica Aquino, Resident Care ManagerTIME COMPLETED:
05:15 PM
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On 01/10/2023, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to conduct a Case Management Inspection concerning an Unusual Incident Report (UIR) about R1's medical emergency on 01/01/2023. LPA met with Danica Aquino, Resident Care Manager (RCM), who had submitted the report to the Regional Office.

During the meeting, the LPA and RCM discussed R1's medical treatment and the proper completion of the LIC624 when submitting a UIR by the next working day (State of California working day) and the 7 day deadline for reporting unusual incidents to Community Care Licensing in writing.

No citations were issued.

Exit interview conducted and copy of this report provided via email.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 01/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2023
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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