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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201277
Report Date: 09/06/2024
Date Signed: 09/06/2024 11:08:17 AM

Document Has Been Signed on 09/06/2024 11:08 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:CARE WITH LOVE FACILITY INC.FACILITY NUMBER:
079201277
ADMINISTRATOR/
DIRECTOR:		KING, QUAMEFACILITY TYPE:
735
ADDRESS:3108 SAINT CHRISTOPHER CTTELEPHONE:
(415) 532-4896
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 6CENSUS: 0DATE:
09/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Quame King, AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:20 AM
NARRATIVE
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On 9/62024 at 09:30am, Licensing Program Analyst (LPA) L. Hall conducted an unannounced annual required inspection. LPA met with Quame King, Administrator, and explained the purpose of the visit. The facility’s fire clearance was approved for six (6) ambulatory clients. Facility does not have any clients and is not operating at this time.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, garage, and back yard. The facility consists of four (4) bedrooms and two (2) bathrooms. All indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for in facility is maintained at 77 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 111.8 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. The supply of extra hygiene was available for residents.

Smoke detectors/carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 8/18/2023. First aid kit was observed to be complete.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/06/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: CARE WITH LOVE FACILITY INC.
FACILITY NUMBER: 079201277
VISIT DATE: 09/06/2024
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Continued from LIC809.

LPA reviewed Administrator file.

The following forms to be updated and submitted to CCLD by 9/13/2024:
  • LIC610D Emergency disaster plan
  • LIC500 (Personnel Record)
  • LIC308 (Designation of facility Responsibility)


The following deficiency was observed:
  • Facility does not have a certified administrator.

The deficiency is observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalties.

Exit interview conducted. A copy of the appeal rights and this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/06/2024 11:08 AM - It Cannot Be Edited


Created By: Laura Hall On 09/06/2024 at 10:33 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CARE WITH LOVE FACILITY INC.
FACILITY NUMBER: 079201277

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064(b)
Administrator Qualifications and Duties
(b) All adult residential facilities shall have a qualified and currently certified administrator.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in having a certified administrator for facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/23/2024
Plan of Correction
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Administrator on record agreed to take required recertification classes and submit certification to CCLD by POC.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2024


LIC809 (FAS) - (06/04)
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