<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201135
Report Date: 05/03/2024
Date Signed: 05/03/2024 10:58:26 AM

Document Has Been Signed on 05/03/2024 10:58 AM - 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:UPPER ROOM OF SAN RAMON LLCFACILITY NUMBER:
079201135
ADMINISTRATOR/
DIRECTOR:		CASIPIT, ANGELITAFACILITY TYPE:
735
ADDRESS:3295 ENSENADA DR.TELEPHONE:
(925) 216-5271
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY: 6CENSUS: 4DATE:
05/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Administrator, Jesus CasipitTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 5/03/2024 at 8:50 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Jesus Casipit and explained the purpose of the visit. The facility’s fire clearance was approved for 6 ambulatory. All residents were away during visit.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 5 total bedrooms which 3 bedrooms are for the clients and 2 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. Temperature was maintained at 65 degree 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 114.8 degree Fahrenheit. All toilets, hand washing and bathing are safe, sanitary and in operating condition. The supply of extra hygienes were available for clients. There is a minimum of one week supply of non-perishables and 2-day perishables food supply. Freezer measured at 0 degrees Fahrenheit and refrigerator measured at 40 degrees Fahrenheit.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 7/13/2024. Emergency Disaster plan was posted. First aid kit was observed to be complete. Fire drill was last conducted on 05/01/2024.

At 9:00am, 4 of 4 clients records were reviewed. At 9:30AM, 2 staff records were reviewed and 2 of 2 have current first aid training and associated to the facility. P&I reviewed and surety bond is sufficient.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2024
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 1