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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201289
Report Date: 08/28/2023
Date Signed: 08/28/2023 11:31:43 AM


Document Has Been Signed on 08/28/2023 11:31 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:SUPRA HOMESFACILITY NUMBER:
079201289
ADMINISTRATOR:GAUTAM, SUJANFACILITY TYPE:
740
ADDRESS:6224 N ARLINGTON BLVDTELEPHONE:
(318) 243-5254
CITY:SAN PABLOSTATE: CAZIP CODE:
94806
CAPACITY:6CENSUS: 0DATE:
08/28/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Sujan Gautam, AdministratorTIME COMPLETED:
11:00 AM
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On 08/28/2023 at 9:30 AM, Licensing Program Analyst (LPA) P. Watson arrived announced to conduct Pre-Licensing inspection. LPA met with Administrator, Sujan Gautam and explained the purpose of the visit. The facility currently has no residents.

LPA toured facility with Sujan including but not limited to 5 bedrooms, 4 bathrooms, kitchen, common areas and backyard. Second floor is only accessible to staff. 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 66 degrees Fahrenheit. Hot water temperature was maintained at 147.3 degrees Fahrenheit in bathroom 2 and 149.8 degrees Fahrenheit in bathroom 3. First-aid kit was observed to be complete. Smoke detectors and carbon monoxide were operational. Fire extinguisher was last serviced on 06/13/2023.

Prior to licensure, the following shall be corrected and faxed to CCL by 09/01/2023.

- Water heater needs to be adjusted, hot water needs to be retested. Hot water in bathroom 2 and 3 were not within range of 105 - 120 degrees Fahrenheit.


Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris WatsonTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2023
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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