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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201286
Report Date: 02/05/2025
Date Signed: 02/05/2025 11:51:36 AM

Document Has Been Signed on 02/05/2025 11:51 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:HAZEL COURT HOMEFACILITY NUMBER:
079201286
ADMINISTRATOR/
DIRECTOR:		VIZCONDE, GIANNE P.FACILITY TYPE:
735
ADDRESS:248 HAZEL COURTTELEPHONE:
(650) 863-6708
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 4CENSUS: 0DATE:
02/05/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Gianne Vizconde, Administrator/
Domingo Lalaquit, Administrator		TIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 02/05/2025 at 10:30am, Licensing Program Analyst (LPA) T. Syess-Gibson conducted an unannounced annual required inspection. LPA met with Gianne Vizconde, Administrator and explained the purpose of the visit. The Administrator currently holds a certificate (#7033023735) that expires on 09/13/2026. The facility’s fire clearance was approved for four (4) ambulatory clients. LPA observed no clients during visit. Licensee is waiting for vendor (RCEB) to place clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, garage, and back yard. The facility consists of three (3) total bedrooms and two (2) bathrooms. Unit in backyard unused by staff. All indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 69 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 115.9 degrees Fahrenheit. Staff was washing during inspection. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Paper towel, and soap observed at all hand washing stations. The supply of extra hygiene was available for residents. The facility is waiting for clients. Administrator will supply more food before first client is placed at facility.

Smoke detectors/carbon monoxide were in operating condition during visit. Fire extinguisher was last services on 09/17/2024. No fire drill has been conducted as of today, once clients are placed facility will conduct fire drill. First aid kit was observed to be complete.

Continued LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/05/2025
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 2
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: HAZEL COURT HOME
FACILITY NUMBER: 079201286
VISIT DATE: 02/05/2025
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Continued from LIC809.

LPA reviewed two (2) staff files, and both were current and complete.

The following forms to be updated and submitted to CCLD by 02/12/2025:

· Surety Bond
· LIC500 (Personnel Record)
· LIC308 (Designation of facility Responsibility)
· LIC400 (Affidavit Regarding Client/Resident Cash Resources)
· LIC610D (Emergency Disaster Plan)


No deficiencies cited during visit.

Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025
LIC809 (FAS) - (06/04)
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