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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201205
Report Date: 09/01/2022
Date Signed: 09/01/2022 03:14:10 PM


Document Has Been Signed on 09/01/2022 03:14 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:LOVING HANDSFACILITY NUMBER:
079201205
ADMINISTRATOR:MORALES, MA MERCEDES R.FACILITY TYPE:
740
ADDRESS:2621 PRESIDIO DRTELEPHONE:
(925) 330-5129
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:5CENSUS: 0DATE:
09/01/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Mercedes Morales, Applicant TIME COMPLETED:
03:50 PM
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On 09/1/2022 at 01:00 PM, Licensing Program Analyst (LPA) L. Ibo arrived unannounced to conduct a Change of Location Pre-licensing Required inspection. LPA met with Applicant/Administrator Ma. Mercedes Morales and explained the purpose of the visit. The facility currently has no residents living at the facility. Fire clearance was granted on 8/16/2022. LPA observed COVID signs posted in the front entrance, common areas and bathrooms.

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 3 residents’ bedrooms, 1 staff room, 3 bathrooms, kitchen, common areas and backyard. Bathrooms were equipped with grab bars and shower mats. There is sufficient lighting throughout facility. Facility was observed equipped with refrigerator, microwave, dishwasher, washer and dryer. Cabinet for knives, cleaning supplies, and central storage for medications were observed with locks. Activity supplies were available. Hot water temperature was maintained at 110 degrees F. Smoke detectors and carbon monoxide were operational. Pathways inside and outside were free of fire hazards and obstruction. Fire extinguisher were shown to be brand new.

...Continue to LIC809C...

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


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: LOVING HANDS
FACILITY NUMBER: 079201205
VISIT DATE: 09/01/2022
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Applicant agreed to do the following:

To have linens and hygiene supplies available to residents in care.
To have dinner ware and silver wares available for residents' use.
Applicant agreed to have food supplies good for seven days of non-perishables and two days perishables.
Outdoor activity space is available once residents move-in to this location.

Applicant/Administrator agreed to let LPA know once all residents move-in to this location from facility 079200854.

No deficiencies were observed during visit.

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 and a copy of this report provided via email.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022
LIC809 (FAS) - (06/04)
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