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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201253
Report Date: 05/06/2024
Date Signed: 05/06/2024 12:24:21 PM

Document Has Been Signed on 05/06/2024 12:24 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:FUSCHIA COURT HOMEFACILITY NUMBER:
079201253
ADMINISTRATOR/
DIRECTOR:		ROSELLON, EDGARDOFACILITY TYPE:
735
ADDRESS:50 FUSCHIA CTTELEPHONE:
(925) 818-5890
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 6CENSUS: 0DATE:
05/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Edgardo Rosellon AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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On 05/06/2024 at 10:45AM, Licensing Program Analyst (LPA) T. Syess-Gibson conducted an unannounced 1-Year Required inspection. LPA met with Administrator Edgardo Rosellon and explained the purpose of the visit. The Administrator currently holds a certificate (#6055022735). The facility’s fire clearance was approved for six (6) ambulatory residents.

LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of four (4) bedrooms and three (3) bathrooms. All outdoor and indoor passageways are kept free of obstruction. LPA did not observe any bodies of water. A comfortable temperature is maintained at 70 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 115.5 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non skid mats. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 04/25/2024. Emergency Disaster Plan was last posted on 05/03/2024. First aid kit was observed to be complete. No fire drill has been conducted as of today the facility doesn't have any clients.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2024
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 3
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: FUSCHIA COURT HOME
FACILITY NUMBER: 079201253
VISIT DATE: 05/06/2024
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Continued from LIC809.

No Client files reviewed, facility doesn't have any clients at this time. One (1) Staff files reviewed which are current, and complete. LPA reviewed facility transportation (van) documents during visit.

No deficiencies observed during visit.

The following forms to be updated and submitted to CCLD by 05/13/2024:
  • LIC 500 Personnel Report
  • 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: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024
LIC809 (FAS) - (06/04)
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