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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201128
Report Date: 11/17/2023
Date Signed: 11/17/2023 03:22:51 PM

Document Has Been Signed on 11/17/2023 03:22 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:
11/17/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Fernando Fernandez, Administrator TIME COMPLETED:
03:40 PM
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On 11/17/2023 at 2:05PM Licensing Program Analyst (LPA) Kelly Nguyen arrived unannounced to conduct health and safety check due to a P1 complaint. LPA met with Fernando Fernandez, Administrator 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 last inspected on 8/29/2023.

During the visit LPA observed that there are currently no resident residing at the facility.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2023
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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