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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201161
Report Date: 07/07/2022
Date Signed: 07/14/2022 10:55:17 AM


Document Has Been Signed on 07/14/2022 10:55 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:
07/07/2022
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Asha JainTIME COMPLETED:
04:00 PM
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On 7/7/12, LPA J. Sampair successfully completed the Component III training with the Applicant Asha Jain via TEAMS. During the training, Ms. Jain confirmed that she understood this category specific training and ways for her to address some of the commonly found problem areas operating a licensed facility to keep it within substantial Title 22 regulation compliance. Additionally, she demonstrated that she understood and appreciated her part in avoiding the common facility operation problem areas and pitfalls. Further, she expressed a desire to continue learning and willingness to reach out to the Regional Office and her LPA, because the Component III training does not cover ALL regulations, only those found to be most problematic, and that the regulations require Administrators to be knowledgeable of all regulations and amendments to the law.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2022
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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