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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200877
Report Date: 12/13/2023
Date Signed: 12/13/2023 02:42:11 PM

Document Has Been Signed on 12/13/2023 02:42 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:NATIONAL PSYCHIATRIC CARE AND REHAB SERVICES INCFACILITY NUMBER:
079200877
ADMINISTRATOR:AQUINO, CARRIE AFACILITY TYPE:
772
ADDRESS:2181 TICE VALLEY BLVDTELEPHONE:
(925) 478-3795
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94595
CAPACITY: 12CENSUS: 10DATE:
12/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Staffmember Kingsley NwalaTIME COMPLETED:
03:10 PM
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On 12/13/2023 at 08:50 AM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to conduct the Required Annual Inspection of the facility. Upon arrival, LPA stated the purpose of the visit to Staff Members Amber Sun and Kingsley Nwala; Administrator (ADM) Carrie Aquino was informed by phone.

LPA toured facility with Mr. Nwala, thoroughly inspecting the interior and exterior. All outdoor and indoor passageways were free of obstruction. There were no bodies of water observed. Inside, the temperature was measured at a comfortable 74.6 degrees and the hot water was 109.0 degrees Fahrenheit. The LPA observed adequate lighting in all of the rooms for the comfort and safety of the residents. LPA observed 7 days of nonperishable and 2 days of perishable foods on hand. Sharps and dangerous items were inaccessible to residents. Smoke and carbon monoxide detectors were in operating condition. Fire extinguisher was observed to be fully charged and last serviced on 02/18/2023.

The LPA interviewed 3 residents and 4 staff members. LPA reviewed the records of 5 residents and 5 staff members.

No citations were issued.

Exit interview conducted with Mr. Nwala. A copy of this report provided via email to the ADM.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2023
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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