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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201156
Report Date: 04/10/2024
Date Signed: 04/10/2024 08:26:13 PM

Document Has Been Signed on 04/10/2024 08:26 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/
DIRECTOR:		EDWARDS, JAMESFACILITY TYPE:
735
ADDRESS:650 8TH STREETTELEPHONE:
(510) 778-8776
CITY:RICHMONDSTATE: CAZIP CODE:
94801
CAPACITY: 3CENSUS: 3DATE:
04/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Derrick Walker, CaregiversTIME VISIT/
INSPECTION COMPLETED:
12:35 PM
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On 04/10/2024 at 9:00am, Licensing Program Analyst (LPA) Carol Fowler conducted an unannounced annual 1-year required inspection. LPA met with Derrick Walker and Florence Spencer Caregivers and explained the purpose of the visit. The administrator currently holds a certificate (#6061339735) that expired on 06/16/20/2023. The facility’s fire clearance was approved for three (3) ambulatory clients.

LPA toured the facility including but not limited to bedrooms, bathroom, kitchen, common area, and back yard. The facility consists of two (2) total bedrooms and one (1) bathroom. All indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 73 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 105 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 clients. 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 4/4/2024. Fire drill last conducted 3/19/2024. First aid kit was observed to be complete.

Continued on LIC809C.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/10/2024
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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: SAFE SPACE RESIDENTIAL CARE HOME
FACILITY NUMBER: 079201156
VISIT DATE: 04/10/2024
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Continued from LIC809.

Three (3) staff records were reviewed, and three (3) of three (3) staff have first aid certification. LPA reviewed client's record and it was current and complete. LPA reviewed P&I.

The following forms to be updated and submitted to CCLD by 4/19/2024:
  • LIC610D Emergency disaster plan (last page)
  • Liability insurance.
  • Surety Bond
  • LIC500 (Personnel Record)
  • Client Roster
  • LIC308 (Designation of facility Responsibility)
  • LIC400 Affidavit Regarding Client/Resident Cash Resources


No deficiencies cited during visit.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024
LIC809 (FAS) - (06/04)
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