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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201248
Report Date: 05/26/2023
Date Signed: 05/26/2023 11:20:33 AM

Document Has Been Signed on 05/26/2023 11:20 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
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: 15DATE:
05/26/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Gary Peer, AdministratorTIME COMPLETED:
11:30 AM
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On 5/26/2023 at 10:10AM, Licensing Program Analyst (LPA), L. Hall arrived to conduct an unannounced continuation Pre-Licensing Inspection. LPA met with Administrator, Gary Peer, and explained the purpose of the visit.

LPA reviewed three (3) staff and two (2) volunteer files. All were current.

LPA conducted a Component III Review, for the Pre-licensing Inspection which was conducted on 5/15/2023, with Gary Peer, Administrator, and Jean Morrison, Program Director.

LPA presented Component III power point during visit and discussed the regulations embodied in the power point. LPA observed the participants gained knowledge about running and maintaining the facility in accordance with regulations.

A license has not yet been granted to this facility. Licensure is subject to final review and approval by the Centralized Applications Unit. Licensee is not to accept consumers until notified by Community Care Licensing that the license has been approved.

No deficiencies cited during visit.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 05/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/26/2023
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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