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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200849
Report Date: 07/02/2024
Date Signed: 07/02/2024 12:17:33 PM

Document Has Been Signed on 07/02/2024 12:17 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:ALICIAS HEAVENLY CARE HOMEFACILITY NUMBER:
079200849
ADMINISTRATOR/
DIRECTOR:		GONZALEZ, MICHELLEFACILITY TYPE:
735
ADDRESS:2212 TRINITY DRTELEPHONE:
(925) 390-6883
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 6CENSUS: 6DATE:
07/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:08 AM
MET WITH:Michelle Gonzalez, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:25 PM
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On 07/02/2024 at 10:08 AM, Licensing Program Analyst (LPA) T.Syess-Gibson conducted an unannounced annual 1-Year required inspection. LPA met with Michelle Gonzalez,Administrator, and explained the purpose of the visit. The administrator currently holds a certificate (#6045565735) that expires on 05/23/2024. 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 seven (7 total bedrooms and four (4) bathrooms. Four (4) bedrooms used by staff. All indoor passageways are kept free of obstruction. LPA observed a swimming pool with an lock on the gate in the backyard. 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 117.4 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 03/29/2024. Fire Drill last conducted on Emergency Disaster Plan was last posted on 01/20/2024. First aid kit was observed to be complete.

Continued LIC809C

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2024
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: ALICIAS HEAVENLY CARE HOME
FACILITY NUMBER: 079200849
VISIT DATE: 07/02/2024
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Continued from LIC809.

Three (3) staff records were reviewed and all six (6) clients' records reviewed, current, and complete. LPA also reviewed P & I and a sample of medication.


The following forms to be updated and submitted to CCLD by 07/09/2024:

· Surety Bond
· LIC500 (Personnel Record)
· Client Roster
· LIC308 (Designation of facility Responsibility)
· LIC400 Affidavit Regarding Client/Resident Cash Resources
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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: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024
LIC809 (FAS) - (06/04)
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