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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201088
Report Date: 01/26/2023
Date Signed: 01/27/2023 10:13:59 AM


Document Has Been Signed on 01/27/2023 10:13 AM - It Cannot Be Edited

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:OPHELIA PEDROSOFACILITY TYPE:
740
ADDRESS:1300 JUANITA DRIVETELEPHONE:
(925) 945-6833
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94595
CAPACITY:6CENSUS: 6DATE:
01/26/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Telesha ClarkeTIME COMPLETED:
02:40 PM
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On 01/26/2023 at 1:55 PM, Licensing Program Analyst (LPA) J. Sampair arrived to conduct an unannounced Plan of Correction (POC) inspection. Upon entry into the facility, the LPA identified himself and the purpose of the visit to Administrator Consultant Telesha Clarke. They toured facility to verify clearance of the 2 citations.

2 of the 2 POCs were cleared.

Exit interview conducted and a copy of this report provided via email.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2023
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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