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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201218
Report Date: 09/19/2023
Date Signed: 09/19/2023 05:02:54 PM


Document Has Been Signed on 09/19/2023 05:02 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:BYRON PARKFACILITY NUMBER:
079201218
ADMINISTRATOR:RICARDO ROMEROFACILITY TYPE:
740
ADDRESS:1700 TICE VALLEY BLVDTELEPHONE:
(925) 937-1700
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94595
CAPACITY:151CENSUS: DATE:
09/19/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Assistant Executive Director (AED) Iryn MacamayTIME COMPLETED:
05:00 PM
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On 09/19/2023 at 3:00 PM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced for a case management visit concerning the 09/12/2023 incident with R1 and W1 described in the 09/15/2023 unusual incident report. Upon entering facility, LPA stated purpose of visit to Executive Director (ED) Ricardo Romero.

During the visit, the LPA interviewed Assisted Living Director (ALD) Jessica Gurnack. The ALD retold the incident as it was described in the Unusual Incident Report. She also provided an update on the current status of R1, who chose to return to the facility as soon as she was able to after her hospitalization and skilled nursing. She currently has a 24/7 private caregiver assisting her with all activities of daily living during her period of recuperation.

No citations issued during this visit.

Exit interview was conducted with Assistant Executive Director (AED) Iryn Macamay. A copy of this report was provided via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2023
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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