<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200772
Report Date: 10/10/2024
Date Signed: 10/10/2024 06:24:51 PM

Document Has Been Signed on 10/10/2024 06:24 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:REVITALIZE CARE HOME LLCFACILITY NUMBER:
079200772
ADMINISTRATOR/
DIRECTOR:		DACE, GENEVIEVEFACILITY TYPE:
735
ADDRESS:1913 CARDIFF DRTELEPHONE:
(925) 267-9822
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY: 6CENSUS: 5DATE:
10/10/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
05:20 PM
MET WITH:Genevieve Dace, AdministratorTIME VISIT/
INSPECTION COMPLETED:
06:35 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 10/10/2024 at 5:20pm, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct a Case Management visit. LPA met with Administrator, Genevieve Dace, and explained purpose of the visit.

While LPA L. Hall was conducting a complaint investigation 15-AS-20240501163714 on 10/10/2024. Upon arrival LPA observed S2 was not fingerprinted or associated to the facility. S1 did have S2 fingerprinted but it was for the day program.

The deficiency was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency 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: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2024
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 10/10/2024 06:24 PM - It Cannot Be Edited


Created By: Laura Hall On 10/10/2024 at 05:24 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: REVITALIZE CARE HOME LLC
FACILITY NUMBER: 079200772

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/11/2024
Section Cited
CCR
80019(e)(3)

1
2
3
4
5
6
7
80019 (e) All individuals subject to a criminal record review... shall prior to working... in a licensed facility: (3) Request a transfer of a criminal record clearance... This requirement was not met as evidence by:
1
2
3
4
5
6
7
Administrator will have S2 fingerprinted and submit document to CCLD by POC date.
8
9
10
11
12
13
14
Based on observation and record review the Licensee did not comply with the section cited above in having S2 fingerprinted or assoicated to the facility whch may cause a potential health and safety risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 10/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2