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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201173
Report Date: 11/10/2022
Date Signed: 11/10/2022 09:51:41 AM


Document Has Been Signed on 11/10/2022 09:51 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: 1DATE:
11/10/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Whitney Ward, Licensee TIME COMPLETED:
10:05 AM
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On 11/10/2022 starting at 8:40 am, Licensing Program Analyst (LPA) J. Clancy-Czuleger arrived unannounced to conduct a post-Licensing Inspection after facility accepted the 1st resident in September 2022. LPA met with Licensee Whitney Ward and disclosed the purpose of the visit.

During the inspection, LPA toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, kitchen, common areas, and backyard. There is one central entry point for universal screening for staff, residents and visitors. Facility has a sufficient 2-day perishable and one-week non-perishable food supply. Grab bars and non-skid materials were observed in the residents’ bathrooms. Extra linens and towels were observed in the hallway closet.There are no bodies of water observed. Facility has Infection Control Plan, Emergency Disaster Plan, and maintains record of routine screening for residents, staff and visitors. Cabinet for knives, cleaning supplies, and central storage for medications were observed with locks. Fire extinguishers were observed fully charge and tags showed serviced in May of 2022. LPA observed that there is a Physician's Report, Pre-Admission Appraisal, and Admission Agreement on resident's file.


No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2022
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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