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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201191
Report Date: 11/10/2022
Date Signed: 11/10/2022 02:11:43 PM

Document Has Been Signed on 11/10/2022 02:11 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:ODESSA CARE HOME LLCFACILITY NUMBER:
079201191
ADMINISTRATOR:MBURU, RODAHFACILITY TYPE:
735
ADDRESS:186 ODESSA AVENUETELEPHONE:
(510) 220-4470
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY: 6CENSUS: 0DATE:
11/10/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Rodah Mburu, AdmnistratorTIME COMPLETED:
02:15 PM
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On 11/10/2022 at 1:40PM, Licensing Program Analyst (LPA) L. Hall conducted a Component III Review, for the Pre-licensing Inspection which was conducted on this date. with Administrator, Rodah Mburu.

LPA presented Component III power point during visit and discussed the regulations embodied in the power point. LPA observed the participant gained knowledge about running and maintaining the facility in accordance with regulations.

A license has not yet been granted to this facility. Licensure is subject to final review and approval by the Centralized Applications Unit. Licensee is not to accept residents until notified by Community Care Licensing that the license has been approved.

Exit interview conduct and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
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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