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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201253
Report Date: 05/15/2023
Date Signed: 05/15/2023 12:28:19 PM

Document Has Been Signed on 05/15/2023 12:28 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:FUSCHIA COURT HOMEFACILITY NUMBER:
079201253
ADMINISTRATOR:ROSELLON, EDGARDOFACILITY TYPE:
735
ADDRESS:50 FUSCHIA CTTELEPHONE:
(925) 818-5890
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 6CENSUS: 0DATE:
05/15/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:28 AM
MET WITH:Edgardo Rosellon, Licensee/ AdministratorTIME COMPLETED:
11:30 AM
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On 5/15/2023 at 9:28AM, Licensing Program Analyst (LPA) G. Luk conducted an announced Pre-licensing Inspection. LPA met with Licensee/Administrator, Edgardo Rosellon. LPA inspected the facility inside and out including but not limited to bedrooms, bathrooms, dining room, kitchen, living room, garage, and outdoor area. Hot water temperature was measured at 114.8 degrees F. Facility has a locked hallway closet for Medications. First aid kit was complete. Fire extinguisher was observed to the full and last serviced on 2/9/2023. Smoke and carbon monoxide combination detectors were observed. No bodies of water observed. Disaster plan was completed on 3/13/2023. Home was clean and well ventilated with appropriate lighting. Licensee purchased surety bond on December 5, 2022.

Facility has some non-perishable and perishable food supplies. Licensee will purchase additional food supplies prior to admitting clients. There were appropriate number of utensils, plates, bowls, and cups at the facility.

The following will need to be completed before recommending licensure to Centralized Application Bureau (CAB):

1. Facility does not have any chest of drawers for clients and need to obtain some chest of drawers.

2. Facility only had 4 chairs in the bedrooms with fire clearance granted for 6 clients. Licensee will need to obtain 2 additional chairs.

Licensee/Administrator will submit proof of corrections to CCLD on/before 5/22/2023.



Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
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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