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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201079
Report Date: 07/16/2021
Date Signed: 07/16/2021 10:36:21 AM

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:
07/16/2021
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Salina BoatnerTIME COMPLETED:
10:50 AM
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On 7/16/2021 LPA L.Ibo conducted case management in continuation of the pre-licensing visit from 6/18/2021. LPA observed zero clients.

LPA observed the following items were corrected:

1. LIC200 Application for a Community care facility - Corrected, LPA received revised LIC200 and LIC850 that matched the capacity of the facility.
2. Auditory signals for the doors (for dementia care)
3. Stove covers ( for dementia care)

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 Applicant Salina Baotner and a copy of report was given.

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

DATE: 07/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021
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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