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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201173
Report Date: 08/10/2022
Date Signed: 08/10/2022 10:16:17 AM


Document Has Been Signed on 08/10/2022 10:16 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:BUTTERCUP AT OAK GROVEFACILITY NUMBER:
079201173
ADMINISTRATOR:WARD, WHITNEYFACILITY TYPE:
740
ADDRESS:993 OAK GROVE ROADTELEPHONE:
(415) 710-5169
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY:6CENSUS: 0DATE:
08/10/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:41 AM
MET WITH:Whitney WardTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Jill Clancy-Czuleger, conducted an unannounced pre-licensing inspection. License application is for 6 total capacity, of which 2 maybe non-ambulatory. Fire clearance was granted on May 13, 2022. LPA met with Whitney Ward applicant licensee.

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. Facility was observed equipped with refrigerator, microwave, and dishwasher. Cabinet for knives, cleaning supplies, and central storage for medications were observed with locks.

Fire extinguishers were observed fully charge and tags showed serviced May 4, 2022. The two-in-one 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 105.3 degrees Fahrenheit.

LPA observed that facility is ready to be licensed. This report will be submitted to the Central Applications Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required.


Exit interview conducted with Applicant Whitney Ward and a copy of report was provided.


SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2022
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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