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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201079
Report Date: 06/18/2021
Date Signed: 06/18/2021 04:24:04 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:TERESA'S QUALITY COMFORT CARE, LLCFACILITY NUMBER:
079201079
ADMINISTRATOR:BOATNER, SALINAFACILITY TYPE:
740
ADDRESS:1786 CONCANNON DRTELEPHONE:
(925) 206-1947
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY:6CENSUS: 0DATE:
06/18/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Salina BoatnerTIME COMPLETED:
04:40 PM
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On this date, June 18, 2021, Licensing Program Analysts (LPAs) Leslie Ibo and Alicia Delmundo conducted a pre-licensing inspection. LPAs observed no residents were present during today’s visit.

Fire clearance was approved on May 5, 2021. LPAs observed that bedroom #3 can only have 1 resident, bedroom #2 can be shared room and bedroom #1 can be shared room. LPAs recommended to applicant to change LIC200 from capacity 6 to 5.

LPAs toured the entire premises indoors and outdoors. The facility has 3 bedrooms, 2 bathrooms, one story house per facility sketch. 3 bedrooms are designated for residents only. LPAs observed 1 fire extinguisher which located at the garage. Smoke detectors and carbon monoxide detectors were observed operational.


LPAs observed adequate lighting. Hallways and passageways were free of obstructions. Food supplies were sufficient good for 7 days of non-perishables . Linens, bed covers, hygiene and paper product supplies were observed. Knives are kept in a locked cabinet. Laundry supplies are locked in cabinets in the laundry area. Hot water temperature was tested in one of the bathrooms and measured at 105.5 degrees Fahrenheit. First aid kit checked and showed complete with manual. No bodies of water observed.

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

DATE: 06/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021
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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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: TERESA'S QUALITY COMFORT CARE, LLC
FACILITY NUMBER: 079201079
VISIT DATE: 06/18/2021
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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).

The following were discussed and requested to be updated and/or corrected.



1. LIC200 Application for a Community care facility - needs to be submitted to reflect change of capacity from 6 to 5.
2. Auditory signals for the doors (for dementia care)
3. Stove covers ( for dementia care)


COMPONENT III were discussed with applicant.

Once received, LPA will submit LIC200 to CAB analyst who will communicate with the fire department if a re-inspection is needed.

License is pending final review by CAB analyst.

Copy of this report provided to Salina Boatner .
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021
LIC809 (FAS) - (06/04)
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