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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201274
Report Date: 07/14/2023
Date Signed: 07/14/2023 02:24:00 PM

Document Has Been Signed on 07/14/2023 02:24 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:RES SUCCESSFACILITY NUMBER:
079201274
ADMINISTRATOR:BREMNER, IANFACILITY TYPE:
775
ADDRESS:3490 BUSKIRK AVETELEPHONE:
(925) 363-9705
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY: 45CENSUS: 0DATE:
07/14/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Teanna Jerkins, Program ManagerTIME COMPLETED:
01:55 PM
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On 07/14/2023 at 11:35 AM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct Prelicensing inspection due to Change of Location. LPA met with Program Manager and Assistant Program Manager, Teanna Jerkins and Jose Cobian respectively and explained the purpose of the visit. The facility currently has no clients.

LPA toured facility with Teanna and Jose including but not limited the downstairs lower level that included a large multipurpose room, art room, computer lab, sensory rooms, 3 bathrooms, kitchen area, activity room, classrooms and additional common areas. The upper level included a loft, sensory relaxation rooms, staff office spaces, storage and 1 bathroom. There is sufficient lighting throughout the facility. Room temperatures were at 73 degrees F downstairs and 74 degrees F upstairs and hot water temperature was measured at 114, 116 and 120 degrees F. First-aid kits was observed to be complete. Smoke detectors and carbon monoxides were operational. Fire extinguishers were last serviced on 06/15/2023.

No issues noted during inspection. LPA observed that facility is ready to be licensed. This report will be submitted to the Central Applications Branch (CAB) and a final review of the application will be conducted. This facility is not yet licensed, and is subject to final approval by CAB. 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: 07/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/14/2023
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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