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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201088
Report Date: 12/16/2021
Date Signed: 12/16/2021 02:55:07 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:LAFAYETTE RESIDENTIAL CAREFACILITY NUMBER:
079201088
ADMINISTRATOR:MCGILL, TAMRAFACILITY TYPE:
740
ADDRESS:1300 JUANITA DRIVETELEPHONE:
(925) 945-6833
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94595
CAPACITY:6CENSUS: 3DATE:
12/16/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Tamra McGill, ApplicantTIME COMPLETED:
01:30 PM
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On 12/16/2021 at 9:05AM, Licensing Program Analysts (LPAs) C. Lin L. Hall arrived unannounced to conduct Changing Ownership Pre-licensing Required inspection. LPAs met with Administrator Ophelia Perdroso and explained the purpose of the visit. The facility currently has 3 residents. Applicants Phillip and Tamra McGill arrived later.

LPA toured facility including but not limited to 6 bedrooms, 2 bathrooms, kitchen, common areas and backyard. Bedrooms and living rooms were equipped with the proper furniture. Bathrooms were equipped with grab bars. Linens and hygiene supplies were observed inside a cabinet. There is sufficient lighting throughout facility. Room temperature was maintained at 69 degrees F and hot water temperature was maintained at 119 degrees F. First-aid kit was observed to be complete. Smoke detectors and carbon monoxide were operational. Fire extinguisher was last serviced on 08/12/2021.

Prior to licensure, the following shall be corrected and submitted photos of new lock to CCL by 12/20/2021.
  • Chemicals and power tools are inaccessible to residents.


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 and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2021
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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