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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200966
Report Date: 12/01/2023
Date Signed: 12/01/2023 10:39:56 AM


Document Has Been Signed on 12/01/2023 10:39 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:NURTUREHOOD, LLCFACILITY NUMBER:
079200966
ADMINISTRATOR:CRUZ, STEPHANIEFACILITY TYPE:
740
ADDRESS:2755 CALPINE PLTELEPHONE:
(925) 890-9007
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY:6CENSUS: 5DATE:
12/01/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Angel VillocilloTIME COMPLETED:
11:00 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 12/01/23 at 10:00 am Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to do a case management visit. LPA met with staff Angel Villocillo and explained the purpose of the visit. Administrator Stephaine Cruz was called and agreed to have angel sign off on the report.

LPA obtained additional information about an exception that was requested by the facility for a resident who has a stage III ulcer. This resident was previously on hospice but recently graduated. This resident is bed bound and relies on staff for all activities of daily living.

LPA discussed that along with the ulcer exception the facility needed to submit an exception for functional capabilities for R1.




Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 12/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/01/2023
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 1