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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201156
Report Date: 05/23/2022
Date Signed: 05/23/2022 12:42:14 PM

Document Has Been Signed on 05/23/2022 12:42 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:SAFE SPACE RESIDENTIAL CARE HOMEFACILITY NUMBER:
079201156
ADMINISTRATOR:EDWARDS, JAMESFACILITY TYPE:
735
ADDRESS:650 8TH STREETTELEPHONE:
(510) 776-3217
CITY:RICHMONDSTATE: CAZIP CODE:
94801
CAPACITY: 3CENSUS: 0DATE:
05/23/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:James Edwards, AdministratorTIME COMPLETED:
12:00 PM
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On 5/23/2022 at 11:00 AM, Licensing Program Analysts (LPAs) C. Fowler and L. Hall arrived announced to conduct Prelicensing inspection. LPAs met with Administrator, James Edwards and explained the purpose of the visit. The facility currently has no clients.

LPA toured facility including but not limited to 2 bedrooms, 1 bathroom, kitchen, common areas, front and backyard. Bedroom and living rooms were equipped with the proper furniture. Bathrooms were equipped with grab bars and non-skid mats. Linens and hygiene supplies were observed inside a cabinet. There is sufficient lighting throughout facility. Room temperature was maintained at 70 degrees F and hot water temperature was maintained at 105.1 degrees F. First-aid kit was observed to be complete. Smoke detectors and carbon monoxide were operational. Fire extinguisher was last serviced on 10/25/2021.

No issues noted during inspection. LPAs observed that facility is ready to be licensed. This report will be submitted to the Central Applications Beau (CAB) and a final review of the application will be conducted. This facility is not yet licensed, and is subject to final approval by CAB. Additional requirements may still be required.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2022
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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