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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201248
Report Date: 05/15/2023
Date Signed: 05/15/2023 02:01:20 PM

Document Has Been Signed on 05/15/2023 02:01 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:VALLEY OAK RESPITE CENTERFACILITY NUMBER:
079201248
ADMINISTRATOR:PEER, GARYFACILITY TYPE:
775
ADDRESS:989 SAN RAMON VALLEY BLVDTELEPHONE:
(925) 915-0030
CITY:DANVILLESTATE: CAZIP CODE:
94526
CAPACITY: 30CENSUS: 16DATE:
05/15/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Jean Morrison, Program DirectorTIME COMPLETED:
01:20 PM
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On 5/15/2023 at 11:40AM, Licensing Program Analyst (LPA), L. Hall arrived to conduct an announced Pre-Licensing Inspection. LPA met with Jean Morrison, Program Director and explained the purpose of the visit. Administrator, Gary Peer, arrived at 11:55AM. The facility has a fire clearance approved for a capacity of twenty-five (25) ambulatory and five (5) non-ambulatory.

LPA toured facility with Program Director. LPA inspected the facility inside and out including but not limited to common areas, bathrooms, kitchen, and storage. Facility is clean and in good repair. Smoke detector and carbon monoxide detector are in operable condition. First aid kit is complied with regulation. Fire extinguisher was last serviced on 7/11/2022. Water temperature in shared bathroom is 122.5 degrees Fahrenheit. Toxins are locked underneath the sink cabinet. Sharps were locked in kitchen cabinet. Facility does not provide snacks or lunch for clients. Facility does not administer medication at this location.

Prior to licensure, the following shall be corrected by 05/22/2023.
  • All personnel files shall be current and complete.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 05/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2023
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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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: VALLEY OAK RESPITE CENTER
FACILITY NUMBER: 079201248
VISIT DATE: 05/15/2023
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Continued from LIC809.

Issues were noted during inspection. LPA observed that facility is not ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAU. Additional requirements may still be required.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023
LIC809 (FAS) - (06/04)
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