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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201161
Report Date: 07/29/2024
Date Signed: 07/29/2024 02:56:00 PM


Document Has Been Signed on 07/29/2024 02:56 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
OAKLAND ASC, 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:
(925) 287-8994
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:6CENSUS: 3DATE:
07/29/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Administrator/Licensee Asha JainTIME COMPLETED:
03:15 PM
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On 7/29/2024 at 11:15 AM, Licensing Program Analyst (LPA) James Sampair arrived unannounced for a Plan of Correction (POC) visit. Upon entry, LPA stated the purpose of the visit to Administrator/Licensee Asha Jain.

The LPA inspected records and the interior and exterior of the facility and provided a letter of clearance for those POCs that had been completed.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 529-9416
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2024
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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