<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201209
Report Date: 06/05/2023
Date Signed: 06/05/2023 12:12:58 PM


Document Has Been Signed on 06/05/2023 12:12 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:GRAND OAK MANOR SUITE LLCFACILITY NUMBER:
079201209
ADMINISTRATOR:RAMOS, DIGNAFACILITY TYPE:
740
ADDRESS:945 FANED WAYTELEPHONE:
(925) 364-0882
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY:4CENSUS: 0DATE:
06/05/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Digna Ramos (applicant-licensee)TIME COMPLETED:
12:20 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 06/05/2023 at 8:55 am Licensing Program Analyst (LPA) Jill Clancy-Czuleger, conducted an announced pre-licensing inspection. License application is for (4) total capacity, of which 4 maybe non-ambulatory. Fire clearance was granted on August 23, 2022. LPA met with Digna Ramos (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. Food supplies checked and observed good for seven days of non-perishables. 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. Outdoor activity space was observed furnished with tables, chairs and shade.

Fire extinguishers were observed fully charge and tags showed serviced May 3rd, 2023. 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 119.8 degrees Fahrenheit.

Continued on LIC 809-C...
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 06/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2023
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: GRAND OAK MANOR SUITE LLC
FACILITY NUMBER: 079201209
VISIT DATE: 06/05/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
... Continued from LIC 809

There are no corrections to be made.

A exit interview was conducted, and a copy of this report has been provided. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2