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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201215
Report Date: 03/28/2024
Date Signed: 03/28/2024 11:18:29 AM

Document Has Been Signed on 03/28/2024 11:18 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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: DATE:
03/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Remy Banzuela LicenseeTIME COMPLETED:
11:25 AM
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On 03/28/2024 at 9:40AM, Licensing Program Analysts (LPAs) T. Syess-Gibson and Carol Fowler conducted an unannounced annual required inspection. LPAs met with Remy Banzuela, Licensee, and explained the purpose of the visit. Administrator, Keith Benitez, was also present during visit. LPAs toured the facility with Remy Banzuela. The facility’s fire clearance was approved for Six (6) ambulatory clients. Facility doesn't have any clients at this time.

LPAs informed Licensee to contact CCLD when first client moves in.

LPAs toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of four (4) total bedrooms, three (3) for clients, One (1) for staff and three (3) bathrooms. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 62 degrees Fahrenheit. LPAs 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 117.4 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Hand washing poster, paper towel, and soap observed at all hand washing stations. The supply of extra hygiene was available for residents. There is a minimum of 7-day non-perishables and 2-day perishables foods.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2024
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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: PATO LANE HOME
FACILITY NUMBER: 079201215
VISIT DATE: 03/28/2024
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Continued from LIC809.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 11/24/2023. Emergency Disaster Plan was last posted on 01/30/2023. First aid kit was observed to be complete.

No Client files reviewed, facility doesn't have any clients at this time. Two (2) Staff files reviewed which are current, and complete.

The following forms to be updated and submitted to CCLD by 04/04/2024 :

· LIC 500 Personnel Report (Updated)
· LIC 400 Affidavit Regarding Client/Resident Cash Resources
· LIC 402 Surety Bond
· LIC610D emergency disaster plan
· LIC308 Designation of facility responsibility

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024
LIC809 (FAS) - (06/04)
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