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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200757
Report Date: 05/12/2021
Date Signed: 05/12/2021 03:28:54 PM

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:WALNUT CREEK CARE HOMEFACILITY NUMBER:
079200757
ADMINISTRATOR:SANDHU, SEEMAFACILITY TYPE:
740
ADDRESS:2562 VENADO CAMINOTELEPHONE:
(510) 825-2383
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:6CENSUS: 4DATE:
05/12/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Seema Sandhu/Administrator TIME COMPLETED:
02:05 PM
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Licensing Program Analyst (LPA) Delmundo conducted a health and safety inspection as a result of the Department receiving a complaint (Control # 15-AS-20210504155938). LPA informed Seema Sandhu, administrator, that due to Shelter in Place Order by the Governor and management directive to telework, inspection will be done via video conference.

LPA requested Seema Sandhu to tour LPA to the facility starting from the front door. LPA requested to open the front door and exit doors on 3 residents' bedrooms. LPA inspected the living room, kitchen, dining room, bedrooms, bathrooms, side and backyard. There were 2 staff on-duty, Nestor Avecilla and Norma Solon who are both fingerprint cleared and associated to this facility. All 4 residents were present during inspection.

Food supplies were checked and observed sufficient. Facility has sufficient lighting. Hallways and passageways were observed free of obstructions.

Copy of this report provided to Seema Sandhu via e-mail.




SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2021
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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