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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201159
Report Date: 04/25/2022
Date Signed: 04/25/2022 10:47:25 AM


Document Has Been Signed on 04/25/2022 10:47 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:ACE CARE HOMEFACILITY NUMBER:
079201159
ADMINISTRATOR:HSU, MARGARETFACILITY TYPE:
740
ADDRESS:3718 CHAPARRAL CT.TELEPHONE:
(925) 338-2440
CITY:CONCORDSTATE: CAZIP CODE:
94519
CAPACITY:6CENSUS: DATE:
04/25/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Margaret Hsu (applicant administrator)TIME COMPLETED:
10:50 AM
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Licensing Program Analysts (LPA) Jill Clancy-Czuleger conducted an announced pre-licensing inspection. License application is for six (6) total capacity, of which 5 maybe non-ambulatory and 1 maybe bedridden. Fire clearance was granted on March 28, 2022. LPA met with Margaret Hsu (applicant administrator).

LPA inspected the facility inside out. There is no body of water. Physical plant is consistent with the facility sketch received by Central Application Bureau (CAB) and approved by the fire department. LPA inspected the living room, dining area, kitchen, bedrooms, hallways, bathrooms, side and backyards. Bedrooms were observed appropriately furnished with adequate lighting and drawers. Facility has sufficient towels, extra bed sheets and comforters. Equipment and supplies for residents' personal hygiene are available and on site. Dinner and silver wares were observed sufficient for residents' use. Food supplies checked and observed good for seven days of non-perishables. Facility was observed equipped with refrigerator, microwave, dishwasher, washer and dryer. Cabinet for knives, cleaning supplies, and central storage for medications were observed with locks. Activity supplies were available.

Fire extinguishers were observed fully charge. There is a carbon monoxide detector in every room. Both the carbon monoxide and smoke detector tested and observed functional. First aid kit checked and observed complete with manual. Hot water temperature in one of the bathrooms tested and measured at 116.2 degrees Fahrenheit.

....continued on 809-C

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
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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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: ACE CARE HOME
FACILITY NUMBER: 079201159
VISIT DATE: 04/25/2022
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LPA observed the following:
1. latch on exit gates
2. lack of signage for facility


LPA discussed the following:
1. Posting signs throughout the facility
2. Moving latch on exit gate to the inside for emergency’s

Upon receipt of the proof of corrections for the 2 items above, and proof of N95 fit testing by May 16, 2022, LPA Clancy-Czuleger will inform CAB. Issuance of license is pending upon final review by CAB analyst.

Exit interview conducted and copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
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
LIC809 (FAS) - (06/04)
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