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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201271
Report Date: 07/26/2023
Date Signed: 07/26/2023 02:35:53 PM

Document Has Been Signed on 07/26/2023 02:35 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:LAS TRAMPAS - SHEILA HOUSEFACILITY NUMBER:
079201271
ADMINISTRATOR:RUBIO, MARTHAFACILITY TYPE:
740
ADDRESS:9 SHEILA COURTTELEPHONE:
(925) 300-3839
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY: 4CENSUS: 4DATE:
07/26/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Martha Rubio, Assistant Director of ResidentialTIME COMPLETED:
02:10 PM
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On 07/26/2023 at 11:15 AM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a Pre-Licensing inspection. LPA met with Assistant Director of Residential, Martha Rubio and explained the purpose of the visit. The facility currently has a fire clearance for 2 ambulatory and 2 non-ambulatory.

LPA toured facility including but not limited to 4 bedrooms, 2 bathrooms, kitchen, common areas and backyard. Bedrooms and living rooms were equipped with the proper furniture. Bathrooms were equipped with grab bars and non-skid mats. Linens and hygiene supplies were observed inside a linen closet and cabinet. There is sufficient lighting throughout facility. Room temperature was maintained at 72 degrees Fahrenheit and hot water temperatures was measured 109.7 and 107.9 degrees Fahrenheit. First-aid kit was observed to be complete. Smoke detectors and carbon monoxide were operational. Fire extinguisher was last serviced on 01/13/2023. A sample of resident's medications was reviewed.

No issues noted during inspection. LPA observed that facility is 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: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2023
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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