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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201161
Report Date: 07/13/2022
Date Signed: 07/14/2022 01:27:29 PM

Document Has Been Signed on 07/14/2022 01:27 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: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:
07/13/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:10 PM
MET WITH:Asha JainTIME COMPLETED:
04:40 PM
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On 7/13/22 at 4:10 PM, Licensing Program Analyst (LPA) J. Sampair received video and photo proof from Applicant Asha Jain of corrections for the deficiencies cited during the 7/6/22 inspection. After review of that proof of correction, LPA phoned Applicant Jain who then confirmed those corrections verbally. Additionally, she described the work she and her staff have done to not only bring their facility into compliance with the Title 22 regulations, but to go above and beyond in service to the residents of her facility.

Pre-Licensing deficiencies have been resolved. Pre-Licensing is now complete.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
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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