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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201128
Report Date: 09/15/2022
Date Signed: 09/15/2022 03:04:20 PM

Document Has Been Signed on 09/15/2022 03:04 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:NICOLE HOMEFACILITY NUMBER:
079201128
ADMINISTRATOR:FERNANDEZ, FERNANDO C.FACILITY TYPE:
735
ADDRESS:613 MARATHON DRIVETELEPHONE:
(510) 861-5810
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 6CENSUS: 0DATE:
09/15/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Fernando Fernandez, ApplicantTIME COMPLETED:
01:30 PM
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On 9/15/2022 at 10:10AM Licensing Program Analyst (LPA) L. Ibo arrived unannounced to conduct Pre-licensing Inspection. Upon arrival, LPA met with Fernando Fernandez, Administrator and Angelina Erasquin, Applicants and explained the purpose of the visit.

The facility was approved for 6 clients; fire clearance was approved for four (4) ambulatory and 2 non-ambulatory clients. No bedridden approval.

LPA toured facility with Applicant including but not limited to 3 bedrooms, 1 office room, 2.5 bathrooms, kitchen, common areas and backyard. Bedrooms and living rooms were equipped with the proper furniture. Bathrooms were equipped with non-skid mats. Linens and hygiene supplies were observed inside a cabinet. There is sufficient lighting throughout facility. Room temperature was maintained at 77 degrees F and hot water temperature was maintained at 120 degrees F. First-aid kit was observed to be complete. Smoke detectors and carbon monoxide were observed. Two fire extinguishers are brand new purchased on May 22, 2022.

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: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2022
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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