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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201191
Report Date: 02/10/2024
Date Signed: 02/10/2024 03:43:49 PM

Document Has Been Signed on 02/10/2024 03:43 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:
02/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Peter Kaguchia, LicenseeTIME COMPLETED:
03:50 PM
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On 2/10/2024 at 2:10pm, Licensing Program Analyst (LPA) L. Hall conducted an unannounced annual 1-year required inspection. LPA met with Licensee, Peter Kaguchia at 2:45pm, and explained the purpose of the visit. Administrator, Rodah Mburu, arrived at 3:00pm. The administrator currently holds a certificate (#6061795735) that expires on 02/1/2024. The facility’s fire clearance was approved for six (6) ambulatory clients. Facility does not have any clients and is not operating at this time.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, garage, and back yard. The facility consists of five (5) total bedrooms and two (2) bathrooms. Garage converted and has a room for staff. All indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for in facility is maintained at 68 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 114.3 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. The supply of extra hygiene was available for residents.

Smoke detectors/carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 11/30/2023. Emergency disaster plan last updated on 9/11/2023. First aid kit was observed to be complete.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 02/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 LLC
FACILITY NUMBER: 079201191
VISIT DATE: 02/10/2024
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Continued from LIC809.

LPA reviewed Administrator file and it is current and complete.

The following forms to be updated and submitted to CCLD by 2/19/2024:
  • LIC610D Emergency disaster plan
  • LIC500 (Personnel Record)
  • LIC308 (Designation of facility Responsibility)

No deficiencies cited during visit.

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

DATE: 02/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2024
LIC809 (FAS) - (06/04)
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