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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201045
Report Date: 03/01/2024
Date Signed: 03/01/2024 04:33:31 PM

Document Has Been Signed on 03/01/2024 04:33 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:SG FACILITYFACILITY NUMBER:
079201045
ADMINISTRATOR:GRAN, SECINANDOFACILITY TYPE:
735
ADDRESS:990 JENSEN CIRCLETELEPHONE:
(925) 308-3316
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY: 6CENSUS: 4DATE:
03/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Monique Gran, Direct Support ProfessionalTIME COMPLETED:
04:45 PM
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On 3/1/2024 at 2:55pm, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an annual year inspection. LPA met with Monique Gran, Direct Support Professional and explained the purpose of the visit. Administrator, Secinando Gran, arrived at 3:20pm. Administrator holds a certificate #6057060735 that expires on 8/30/2024. The facility's fire clearance is for six (6)) ambulatory clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, garage, and back yard. The facility consists of four (4) bedrooms and two (2 ) bathrooms. One (1) bedroom used for an office. All indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 71 degrees 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 111.1 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Paper towel, and soap observed at all hand washing stations. The supply of extra hygiene was available for residents. There is a minimum of 7-day non-perishables and 2-day perishables foods.

Smoke detectors/carbon monoxide were in operating condition during visit. Fire extinguisher was last services on 6/20/2023. Emergency disaster plan last updated 1/1/2024. Fire drill last conducted 1/19/2024. First aid kit was observed to be complete.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 03/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/01/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: SG FACILITY
FACILITY NUMBER: 079201045
VISIT DATE: 03/01/2024
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Continued from LIC809.

LPA reviewed five (5) staff files, four (4) client files and all are current and complete. LPA also reviewed P & I.

LPA request the following documents to be submitted to CCLD by 3/8/2024
  • LIC 500 Personnel Report
  • LIC 308 Designation of Administrative Responsibility
  • LIC 610D Emergency Disaster Plan (last page)
  • Surety Bond
  • LIC400 Affidavit Regarding Client/Resident Cash Resources


No deficiencies cited during visit.

Exit interview conducted and a copy of this report provided.


SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2024
LIC809 (FAS) - (06/04)
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