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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201128
Report Date: 09/24/2024
Date Signed: 09/24/2024 03:39:57 PM

Document Has Been Signed on 09/24/2024 03:39 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:NICOLE HOMEFACILITY NUMBER:
079201128
ADMINISTRATOR/
DIRECTOR:		FERNANDEZ, FERNANDO C.FACILITY TYPE:
735
ADDRESS:613 MARATHON DRIVETELEPHONE:
(510) 861-5810
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 6CENSUS: 3DATE:
09/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:35 PM
MET WITH:Fernando Fernandez, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:54 PM
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On 09/24/2024 at 1:35pm, Licensing Program Analyst (LPA) T.Syess-Gibson conducted an unannounced annual 1-Year required inspection. LPA met with Fernando Fernandez, Administrator, and explained the purpose of the visit. The administrator currently holds a certificate (#7007628735) that expires on 09/18/2025, per CCLD Portal . The facility’s fire clearance was approved for four (4) ambulatory and two (2) non ambulatory clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, garage, and back yard. The facility consists of four (4) total bedrooms and two (2 ) bathrooms. One (1) bedroom used by staff. All indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 77 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 113.4 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Paper towel, and soap observed at all hand washing stations. The supply of extra hygiene was available for residents. There is a minimum of 7-day non-perishables and 2-day perishables foods.

Smoke detectors/carbon monoxide were in operating condition during visit. Fire extinguisher was last services on 09/16/2024. Fire drill last conducted 09/03/2024. First aid kit was observed to be complete.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/24/2024
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: NICOLE HOME
FACILITY NUMBER: 079201128
VISIT DATE: 09/24/2024
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Continued from LIC809.

Five (5) staff records were reviewed, and all staff have first aid certification. All three (3) clients' records reviewed, current, and complete. LPA also reviewed P&I and medications during visit.

The following forms to be updated and submitted to CCLD by 10/01/2024:
  • Liability insurance.
  • Surety Bond
  • LIC500 (Personnel Record)
  • Client Roster
  • LIC308 (Designation of facility Responsibility)
  • LIC400 Affidavit Regarding Client/Resident Cash Resources
  • LIC610D Emergency Disaster Plan


No deficiencies cited during visit.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
LIC809 (FAS) - (06/04)
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