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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200934
Report Date: 10/19/2023
Date Signed: 10/19/2023 11:19:31 AM

Document Has Been Signed on 10/19/2023 11:19 AM - 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:GRAYSON HOME, THEFACILITY NUMBER:
079200934
ADMINISTRATOR:HAWKINS, MONIQUEFACILITY TYPE:
735
ADDRESS:2436 CARDINAL CTTELEPHONE:
(925) 207-0229
CITY:CONCORDSTATE: CAZIP CODE:
94520
CAPACITY: 6CENSUS: 5DATE:
10/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Monique Hawkins, AdministratorTIME COMPLETED:
11:30 AM
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 10/19/2023 at 9:10 AM, Licensing Program Analyst (LPA) P. Watson arrived unannounced to conduct Required 1 Year Annual inspection. Upon arrival LPA was greeted by caregiver, and explained the purpose of the visit. Administrator, Monique Hawkins, arrived at approximately 10:55 AM. The facility’s fire clearance was approved for 6 Ambulatory.

LPA toured the facility 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 72 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 within range of 105-120 degrees Fahrenheit. All toilets, hand washing stations, and bathing stations are safe, sanitary and in operating condition. The supply of extra hygiene’s were available 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 03/24/2023. Emergency Disaster drills were last conducted on 09/05/2023. 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: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2023
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
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: GRAYSON HOME, THE
FACILITY NUMBER: 079200934
VISIT DATE: 10/19/2023
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
26
27
28
29
30
31
32
At 9:30 AM, LPA reviewed 5 of 5 client records. At 10:10 AM, LPA reviewed 5 of 6 staff records and 5 of 5 have first aid training and associated to the facility. At 10:53 AM, LPA reviewed a sample of 5 of 5 client's medications.


Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 11/09/2023:

LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 402 Surety Bond
LIC 610 D Emergency Disaster Plan
Current Administrator Certificate




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: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2