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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201286
Report Date: 11/29/2023
Date Signed: 11/29/2023 03:29:50 PM

Document Has Been Signed on 11/29/2023 03:29 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:HAZEL COURT HOMEFACILITY NUMBER:
079201286
ADMINISTRATOR:VIZCONDE, GIANNE P.FACILITY TYPE:
735
ADDRESS:248 HAZEL COURTTELEPHONE:
(650) 863-6708
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 4CENSUS: 0DATE:
11/29/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Gianne Vizconde-Lalaquit, Licensee/AdministratorTIME COMPLETED:
03:45 PM
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On 11/29/2023 at 2:00PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced/announced to conduct 1-Year Annual Required inspection. LPA met with Licensees/Administrators, Domingo Lalaquit and Gianne Vizconde-Lalaquit and explained the purpose of the visit. The facility currently has no residents/clients.

LPA toured facility with Domingo and Gianne including but not limited to 3 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 cabinet. There is sufficient lighting throughout facility. Room temperature was maintained at 60 degrees F and hot water temperature was measured at 119.2 degrees F. First-aid kit was observed to be complete. Smoke detectors and carbon monoxide were operational. Fire extinguishers was last serviced on 09/12/23 and 09/20/23.

Starting at 3:00 PM, Component III was completed and presented to Administrators/Licensees.

No issues noted during inspection. LPAs observed that facility is ready to be licensed. This report will be submitted to the Central Applications Bureau (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: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/29/2023
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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