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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200883
Report Date: 07/24/2023
Date Signed: 07/24/2023 01:50:16 PM

Document Has Been Signed on 07/24/2023 01:50 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:LA CALLE HAVENFACILITY NUMBER:
079200883
ADMINISTRATOR:LIPARDO, MELISSAFACILITY TYPE:
735
ADDRESS:1775 LA CALLETELEPHONE:
(925) 822-3610
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY: 6CENSUS: 6DATE:
07/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Dennis Valencia, House ManagerTIME COMPLETED:
02:00 PM
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On 07/24/2023 at 9:15 AM, Licensing Program Analyst (LPA) P. Watson arrived unannounced to conduct Required 1 Year Annual inspection. Upon arrival LPA was greeted by caregivers, LPA explained the purpose of the visit. Administrator was unable to join the visit and allowed the House Manager, Dennis Valencia, to sign the documents. The facility’s fire clearance was approved for 6 Ambulatory.

LPA toured the facility with Dennis including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 4 total bedrooms which 3 bedrooms are occupied by the clients and 1 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 70 degree 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 120 degree Fahrenheit. All toilets, hand washing stations, and bathing stations are safe, sanitary and in operating condition. LPA observed a supply of extra hygiene items for clients. There is a minimum of 7 day supply of non-perishables and 2 day perishables food supply.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 11/10/2022. First aid kit was observed to be complete.

Report continues on 809 C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Paris Watson
LICENSING EVALUATOR SIGNATURE: DATE: 07/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: LA CALLE HAVEN
FACILITY NUMBER: 079200883
VISIT DATE: 07/24/2023
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At 11:40 AM, LPA reviewed 6 of 6 clients records. At 12:45 PM, LPA reviewed 6 of 17 staff records and 6 of 6 have current first aid training and associated to the facility. At 1:30 PM, LPA reviewed a sample of 6 of 6 clients medications.


Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 08/14/2023:

LIC 500 Personnel Report
LIC 309 Administrative Organization
LIC 400 Affidavit Regarding Client/Resident Cash Resources
LIC 610 D Emergency Disaster Plan



No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Paris Watson
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023
LIC809 (FAS) - (06/04)
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