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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201123
Report Date: 11/30/2021
Date Signed: 11/30/2021 03:54:49 PM

Document Has Been Signed on 11/30/2021 03:54 PM - 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:LEE FAMILY CARE HOME #4FACILITY NUMBER:
079201123
ADMINISTRATOR:TUCKER, WILLIAMFACILITY TYPE:
735
ADDRESS:18 BROOKS CTTELEPHONE:
(925) 354-2254
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 6CENSUS: DATE:
11/30/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Maureen Lee, LicenseeTIME COMPLETED:
04:00 PM
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On 11/30/2021 at 3:10 PM, Licensing Program Analyst (LPA) J. Clancy-Czuleger and L. Francisco, conducted an unannounced pre-licensing inspection. LPAs met with Maureen Lee Licensee and. Fire clearance was granted for 6 ambulatory only.

LPA inspected the facility inside out. There is no body of water. Physical plant is consistent with the facility sketch received by Central Application Bureau (CAB) and approved by the fire department. LPAs inspected the living room, dining area, kitchen, bedrooms, hallways, bathrooms, side and backyards. Bedrooms were observed appropriately furnished with adequate lighting and drawers. Facility has sufficient towels, extra bed sheets and comforters. Equipment and supplies for residents' personal hygiene are available and on site. Dinner and silver wares were observed sufficient for residents' use. Food supplies checked and observed good for seven days of non-perishables. Cabinet for knives, cleaning supplies, and central storage for medications were observed with locks. Activity supplies were available. Outdoor activity space was observed furnished with tables, chairs and shade. Fire extinguishers were observed fully charge and tags showed serviced 06/02/2021. The two-in-one carbon monoxide and smoke detector tested and observed functional. First aid kit checked and observed complete with manual. Hot water temperature in one of the bathrooms tested and measured at 111.3 degrees Fahrenheit.

Component III is being waived, Licensee is currently an administrator at sister facilities. 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 this report provided
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2021
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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