<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201090
Report Date: 09/13/2021
Date Signed: 09/13/2021 11:41:31 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:A SPRINGTIME RESIDENCEFACILITY NUMBER:
079201090
ADMINISTRATOR:TRUCKS, CHRISTINAFACILITY TYPE:
740
ADDRESS:2752 MOHAWK CR.TELEPHONE:
(415) 290-7611
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY:6CENSUS: 6DATE:
09/13/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Christina Trucks, Licensee/AdministratorTIME COMPLETED:
11:55 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 9/13/2021 starting at 9:45am, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to conduct Prelicensing Inspection. Upon arrival, LPA was greeted by Care Staff, Bunny Magpanpay. Licensee/Administrator, Christina Trucks later arrived at 10:38am.

LPA toured facility including but not limited to residents bedrooms, common areas, kitchen, bathrooms and backyard. A comfortable room temperature was maintained at 70 degrees F. Hot water temperature was maintained at 112.6 degrees F. LPA observed 2 day perishable and one week non-perishable food supply. All bedrooms were fully furnished and clean. Bathrooms were equipped with grab bars and non-skid mats. Centrally stored medications were locked and inaccessible to residents. Sharps and cleaning supplies were locked. Indoor and outdoor passageways were free of obstruction. Carbon monoxide and smoke detectors were observed. First aid kit was complete. Fire extinguisher was last serviced on 2/03/2021. Emergency Disaster Plan was last updated on July 2021.

No issues noted during inspection. LPAs 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 and a copy of report provided.

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

DATE: 09/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1