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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201059
Report Date: 05/19/2021
Date Signed: 05/20/2021 12:42:52 PM

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:CARE 4 ONE INCFACILITY NUMBER:
079201059
ADMINISTRATOR:ELEGADO, LIZA JAY S.FACILITY TYPE:
740
ADDRESS:3938 COWELL RDTELEPHONE:
(925) 464-3891
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY:6CENSUS: 6DATE:
05/19/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Liza ElegadoTIME COMPLETED:
02:30 PM
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At around 1:30pm, Licensing Program Analysts (LPAs) Luisa Fontanilla and Carol Fowler conducted an unannounced pre licensing televisit and met with applicant Liza Elegado. This pre licensing inspection is being conducted due to change of ownership of the facility.

LPAs with Elegado toured the facility inside and out including but not limited to resident bedrooms, living room, kitchen, garage, medication room and backyard. Facility has an approved fire clearance dated 1/25/2021 for 5 nonambulatory and 1 bedridden residents. There are 4 bedrooms and 3 bathrooms. The following posters were observed: Personal Rights, Complaint Poster and Resident Council . Covid related signs were available. There was a screening table with thermometer, sanitizer, questionnaire and log observed. Bedrooms were observed furnished with a bed, dresser, closet, night stand, lamp and chair. Hallways and passageways were free of obstruction. There was sufficient lighting and furniture. The kitchen was observed clean and organized. There was sufficient supply of perishable and non perishable foods. Plates, silver wares and glass wares were observed available. There were separate locked cabinets for resident/ staff files and medicines in the medication room. There was sufficient supply of towels, sheets, blankets and hygiene products observed. Separate locked drawers for knives/ sharp objects and cleaning chemicals were in the kitchen. There was sufficient supply of perishable and non perishable foods. Refrigerator temperature measured at 40 F and freezer temperature was at 0 F. Hot water temperature measured at 115 F. LPA observed passageways were free of obstruction. There is appropriate lighting in the facility and each room. Shower has non skid mats.

LPA observed that facility is ready to be licensed. This report will be submitted to the Central Applications Branch (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required.
Exit interview conducted and a copy of this report was provided to Applicant via email.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2021
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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