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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200934
Report Date: 10/16/2024
Date Signed: 10/16/2024 10:31:37 AM

Document Has Been Signed on 10/16/2024 10:31 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:GRAYSON HOME, THEFACILITY NUMBER:
079200934
ADMINISTRATOR/
DIRECTOR:
HAWKINS, MONIQUEFACILITY TYPE:
735
ADDRESS:2436 CARDINAL CTTELEPHONE:
(925) 207-0229
CITY:CONCORDSTATE: CAZIP CODE:
94520
CAPACITY: 6CENSUS: 6DATE:
10/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:05 AM
MET WITH: Cecilia Hawkins, Care Staff (S2) TIME VISIT/
INSPECTION COMPLETED:
10:45 AM
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On 10/16/24 around 08:05 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct a Required 1-year inspection. LPA was greeted by Ruel Secondez, Care Staff (S1) and advised him of the purpose for the visit. S1 telephoned Cecilia Hawkins, Care Staff (S2) and she arrived around 09:25 AM.

LPA and S2 toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All passageways were free of obstruction; no bodies of water were present. There was a comfortable temperature for clients at 73 degrees F. LPA observed adequate lighting and furniture in all rooms for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom measured at 110.8 F. The shared bathrooms had soap, hand towels and garbage cans. PPE, sanitizer, and paper goods remain sufficient. There was a 2-day supply of perishable foods and a 7-day supply of non-perishable foods. Smoke detectors/carbon monoxide unit were in operating condition during visit. Fire extinguisher was last serviced on 07/25/52024. Emergency Disaster drill was last conducted on 09/28/24. Staff, resident and First Aid kit observed complete.

The following forms are to be updated and submitted to CCLD 10/23/24:
-LIC500 Personnel Report (Reviewed)
-LIC308 Designation of Administrative Responsibility (Reviewed)
-LIC610 Emergency Disaster Plan (Reviewed)
-An updated copy of Administrator Certificate (Upon receipt)
-Resident Roster

No deficiencies cited. Exit interview conducted. A copy of this report provided to Cecilia Hawkins, Care Staff.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2024
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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