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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201067
Report Date: 04/30/2021
Date Signed: 04/30/2021 05:12:39 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:A FAMILY OF CARE NO. 2FACILITY NUMBER:
079201067
ADMINISTRATOR:WILLIAMS, BRENDAFACILITY TYPE:
740
ADDRESS:2410 SMITH RDTELEPHONE:
(925) 876-6746
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:6CENSUS: 0DATE:
04/30/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Brian FriedelTIME COMPLETED:
05:30 PM
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On 04/30/2021 Licensing Program Analyst (LPA) Leslie Ibo made a scheduled tele visit to this facility for the purpose of completing a Pre-licensing inspection. LPA met with Applicant Brian Friedel & Brenda Wiliamson. LPA observed no residents were present during today’s visit.

At 1:00 PM , LPA toured the entire premises indoors and outdoors. The facility has 4 bedrooms , 3 1/2 bathrooms, one story house per facility sketch. 3 bedrooms are designated for residents & 1 bedroom for facility staff. LPA observed 2 fire extinguishers which was in the kitchen and one fire extinguisher adjacent to bedroom #2 & #3. Smoke detectors and carbon monoxide detectors were observed operational. The facility received a fire clearance dated 03/25/2021 with an approval for a total capacity of 6 residents, approved for 6 non-ambulatory residents.

LPA observed a locked cabinet for centrally stored medications at the laundry room. Kitchen and dining room floors are clean and sanitary, food preparation area has an operating ventilation fan, there are no pesticides, poisons, or other toxins stored in any food storage or preparation area, cleaning supplies are kept separate from food supply. The facility has a supply of 7 days of non-perishable and have at least 2 days perishable food. There are enough amounts of tableware, tables, dishes, and utensils. There are enough amounts of equipment for the storage & preparation of food. All equipment and dishes are clean and in good repair and there is at least 1 dining room convenient to the kitchen. Hot water temperature was tested at 111.11 degrees Fahrenheit. Refrigerator temperature was observed at 37 degrees Fahrenheit and freezer was observed at 0 degrees Fahrenheit.
Continue LIC809C...
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2021
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 2
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: A FAMILY OF CARE NO. 2
FACILITY NUMBER: 079201067
VISIT DATE: 04/30/2021
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3 Bedrooms were observed furnished with a bed, bedding, and night stand, a chair, and a closet space. There were no bodies of water present at the facility. Outside pathways to security exit gate were unobstructed. There is confidential storage for personnel and resident records. There are games, activity supplies, and reading materials available. There is an outdoor area, that appears comfortable and furnished for residents to entertain friends and relatives. LPA observed the first aid kit was complete with manual.

During today's visit, LPA reviewed LIC 610E Emergency disaster plan/Fire and Earthquake drill requirements with applicant. LPAs observed the facility had the necessary posters in place (Complaint poster, LTCO poster, Rights to Council, etc). COVID-19 posters were also displayed in the main entrance, common areas and the bathrooms.

Comp III was discussed with Applicant.

LPA recommends approval for the license is pending, until the following item is completed:

· Active telephone line that will be available for residents

Exit interview conducted with Applicant Brian Friedel & Brenda Williamson and a copy of report will be emailed.

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2021
LIC809 (FAS) - (06/04)
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