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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201161
Report Date: 07/06/2022
Date Signed: 07/07/2022 08:59:50 AM


Document Has Been Signed on 07/07/2022 08:59 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:WALNUT CREEK CARE HOMEFACILITY NUMBER:
079201161
ADMINISTRATOR:JAIN, ASHAFACILITY TYPE:
740
ADDRESS:2562 VENADO CAMINOTELEPHONE:
(510) 449-5939
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:6CENSUS: 5DATE:
07/06/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Asha JainTIME COMPLETED:
06:00 PM
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On 07/06/22, Licensing Program Analyst (LPA) James Sampair conducted an unannounced pre-licensing inspection and met with Applicant, Asha Jain. LPA explained purpose of the visit.

LPA toured the facility inside and outside including but not limited to resident's bedrooms, bathrooms, dining room, common living areas, kitchen, and backyard. Resident's rooms were equipped with the proper furniture, but inadequate lighting. Resident's rooms had proper bedding and linens. Bathrooms were equipped with grab bars and nonskid mats. Living room is equipped with the proper furniture for the residents. All toxins and sharp objects were locked. Passageways and hallways were free of obstruction. Fire extinguisher is fully charged. Smoke and Carbon Monoxide detectors were operational. Medication cabinet was locked

Hot water temperature was acceptable at 111 degrees F, the room temperature was 73.6 degrees F, and the freezer temperature was acceptable at 0 degrees F. There were sufficient 2 day perishable and 1 week non-perishable food supplies observed in the refrigerator, freezer, and additional food supplies were observed in storage in the garage. Complaint poster, personal rights, Ombudsman and rights to council posters were observed displayed near the dining area.

Current Licensee cited for 2 Type-B deficiencies:

This facility is not yet licensed and is subject to final approval by CAU. Additional requirements may still be required.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2022
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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