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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200995
Report Date: 01/31/2024
Date Signed: 01/31/2024 05:00:47 PM


Document Has Been Signed on 01/31/2024 05:00 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:CAREFRONT RESIDENTIAL LIVING, LLCFACILITY NUMBER:
079200995
ADMINISTRATOR:WANG, DINGFACILITY TYPE:
740
ADDRESS:4086 TULARE DRTELEPHONE:
(925) 890-8953
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY:6CENSUS: 4DATE:
01/31/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Licensee Angela WangTIME COMPLETED:
05:00 PM
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On 1/31/2024 at 3:00 PM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to meet in person with Licensee Angela Wang concerning the requests for exceptions for residents R1, R2, and R3 Percutaneous Endoscopic Gastrostomy (PEG) tube. Upon arrival, the LPA stated the purpose of the visit to caregivers Teo Rivera and Maria Rivera. The Licensee arrived at approximately 3:20 PM.

During the visit, the LPA and Licensee discussed the requests for exceptions and what updates were required in the Care Plans for R1, R2, and R3 for those exceptions to be granted. The LPA met residents R2 and R3 and observed their Percutaneous Endoscopic Gastrostomy (PEG) tube care.

No citations issued during visit.

Exit interview conducted with Maria Rivera. A copy of this report sent to Licensee via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2024
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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