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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201215
Report Date: 02/01/2023
Date Signed: 02/01/2023 04:09:23 PM

Document Has Been Signed on 02/01/2023 04:09 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:PATO LANE HOMEFACILITY NUMBER:
079201215
ADMINISTRATOR:BENITEZ, KEITH PAUL AFACILITY TYPE:
735
ADDRESS:3847 PATO LANETELEPHONE:
(650) 834-1301
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 6CENSUS: 0DATE:
02/01/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH: KEITH PAUL BENITEZ & REMY BANZUELA, APPLICANT/LICENSEE'STIME COMPLETED:
12:10 PM
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On 02/01/2023 at 9:30 AM, Licensing Program Analyst (LPA) L. Ibo arrived to conduct a Pre-Licensing inspection. LPA met with Licensee/Applicant, Keith Benitez and Remy Banzuela.

The facility's fire clearance was approved for 6 ambulatory clients.

LPA toured facility including but not limited to client's bedrooms, bathrooms, living room, kitchen, garage, and outdoor area. Bedroom #1 (masters bedroom) and bedroom #3 approved for 2 clients and bedroom #2 & 4 is approved for 1 client only. Client's rooms were fully furnished and clean. Hot water was measured at 109.9 degrees F in the bathroom sink. LPA observed lighting in all rooms. LPA observed facility had some non-perishable and perishable food supply. Licensee will purchase additional food supplies once facility is licensed. Smoke detectors and carbon monoxide detectors were observed in operating conditions. First aid kit was complete. Indoor and outdoor passageways were free of obstruction. Fire extinguisher was observed to be full and last serviced in July 2022. Emergency disaster plan was complete. Facility completed infection control plan.

No issues noted during inspection. LPA observed that facility is ready to be licensed. This report will be submitted to the Centralized Application 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.

LPA conducted Component III with Licensee during inspection. LPA presented Component III Power Point and discussed the regulations embodied in the presentation.



Exit interview conducted and a copy of this report provided
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 02/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/01/2023
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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