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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201071
Report Date: 03/19/2025
Date Signed: 03/19/2025 12:23:15 PM

Document Has Been Signed on 03/19/2025 12:23 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:PICADILLY HOME CAREFACILITY NUMBER:
079201071
ADMINISTRATOR/
DIRECTOR:		SANTOS, CHARLIEFACILITY TYPE:
735
ADDRESS:1221 PICADILLY LANETELEPHONE:
(925) 849-7743
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 4CENSUS: 3DATE:
03/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Administrator, Matthew Tobias TIME VISIT/
INSPECTION COMPLETED:
12:35 PM
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On 03/19/2025 at 10:00AM, Licensing Program Analyst (LPA) T. Syess-Gibson conducted an unannounced 1-Year Required inspection. LPA met with Administrator Matthew Tobias and explained the purpose of the visit. The Administrator currently holds a certificate (#7027126735) pending per CCLD portal. Facility has census of 4. LPA observed one (1) client in room resting. The facility’s fire clearance was approved for four (4) ambulatory residents.

LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of four (4) bedrooms and three (3) bathrooms. All outdoor and indoor passageways are kept free of obstruction. LPA did not observe any bodies of water. A comfortable temperature is maintained at 68 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 110.0 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 10/09/2024. Emergency Disaster Plan was last posted on 03/14/2025. First aid kit was observed to be complete. Fire drill was last conducted on 01/20/2025.

Continued on LIC809C.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2025
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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: PICADILLY HOME CARE
FACILITY NUMBER: 079201071
VISIT DATE: 03/19/2025
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Continued from LIC809.

Three (3) staff records were reviewed. LPA reviewed all three (3) resident records, and they were current and complete. LPA reviewed P&I and a sample of medication.

LPA requested the following documents to be submitted to CCLD by: 03/26/2025.

  • Surety Bond
  • LIC500 (Personnel Record)
  • LIC308 (Designation of facility Responsibility)
  • LIC400 (Affidavit Regarding Client/Resident Cash Resources)
  • LIC610D (Emergency Disaster Plan)

No deficiencies cited during visit.

Exit interview conducted. A copy of this report provided to Matthew Tobias

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025
LIC809 (FAS) - (06/04)
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