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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201077
Report Date: 05/25/2021
Date Signed: 05/25/2021 02:08:02 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:TREE HOME FOR SENIORS LLC, THEFACILITY NUMBER:
079201077
ADMINISTRATOR:SHARMA, VIKRAM VIRFACILITY TYPE:
740
ADDRESS:1069 SANTA LUCIA DRTELEPHONE:
(925) 566-4156
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY:6CENSUS: 0DATE:
05/25/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Vikram Sharma, LicenseeTIME COMPLETED:
10:50 AM
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On 5/25/2021 at 09:35am Licensing Program Analyst (LPA) L. Hall conducted an announced pre-licensing inspection and met with Vikram Sharma, Licensee. The fire clearance is for 2 ambulatory, 3 non-ambulatory, and 1 bedridden.

LPA toured the residents bedrooms, bathrooms, dining room, common living areas, kitchen, and backyard. There are four (4) bedrooms and two (2) bathrooms. There is sufficient lighting around the facility. Residents rooms are equipped with the proper furniture, bedding and lighting. Bathrooms were equipped with grab bars and non-skid mats . Passageways and hallways are free of obstruction. Hot water temperature is measured at 116.1 degrees Fahrenheit. LPA observed locked cabinets that will store medications, toxins and sharps. Required posters are posted on the wall. Thermometer in hallway showed temperature as 68 degrees F. Emergency disaster plan dated 05/02/2021. Fire extinguisher was last serviced on 04/09/2021. First Aid kit was complete. Carbon monoxide and smoke detectors were in working condition.

No issues noted during inspection. LPA observed that facility is ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAU. Additional requirements may still be required.

Exit interview conducted with Licensee and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2021
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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