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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201135
Report Date: 04/25/2022
Date Signed: 04/25/2022 12:51:34 PM

Document Has Been Signed on 04/25/2022 12:51 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:UPPER ROOM OF SAN RAMON LLCFACILITY NUMBER:
079201135
ADMINISTRATOR:CASIPIT, ANGELITAFACILITY TYPE:
735
ADDRESS:3295 ENSENADA DR.TELEPHONE:
(925) 216-5271
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY: 6CENSUS: 4DATE:
04/25/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Angelita Casipit, AdministratorTIME COMPLETED:
01:05 PM
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On 4/25/2022 at 11:30 AM, Licensing Program Analysts (LPAs) L. Francisco and K. Nguyen arrived unannounced to conduct Pre-licensing Inspection. Upon arrival, LPAs met with Care Staff Ronald Corum and explained the purpose of the visit. Administrator, Angelita Casipit later arrived at 11:50 AM. The facility's fire clearance was approved for six ambulatory clients. The facility currently is licensed as a group home with 4 existing clients. However, facility is in the process of changing facility type and inspection is being conducted as a new Adult Residential Care Facility (ARF) facility.

LPAs toured facility with Care Staff and Administrator including but not limited to 3 bedrooms, 1 staff room, 3 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 68 degrees F and hot water temperature was maintained at 106 degrees F. First-aid kit was observed to be complete. Smoke detectors and carbon monoxide were operational. Fire extinguisher was last serviced on 12/2/2021.

Prior to licensure, the following shall be corrected by May 2, 2022
-Repair refrigerator Handle
-Remove extra bedframes in bedroom
-Repair light switch in client's bathroom
-Install fire place cover
-Equip each client's room with bedside table

Exit interview conducted and a copy of this report provided. LPA will return to follow-up and complete COMP III at a later time.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Lizette Francisco
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2022
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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