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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201325
Report Date: 04/25/2024
Date Signed: 04/25/2024 01:35:57 PM

Document Has Been Signed on 04/25/2024 01:35 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:WOODLANDS IVFACILITY NUMBER:
079201325
ADMINISTRATOR/
DIRECTOR:		CHAUDHRY, TAYYABAFACILITY TYPE:
740
ADDRESS:3292 WALNUT LNTELEPHONE:
(925) 433-6000
CITY:LAFAYETTESTATE: CAZIP CODE:
94549
CAPACITY: 6CENSUS: 0DATE:
04/25/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Tayyaba ChaudryTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On this day at around 10:45 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct pre-licensing inspection. Licensee/Applicants Tayyaba and Ejaz Chaudry arrived at the facility at around 12:05 pm.

During the visit, LPA toured the facility with the applicants. Physical plant is consistent with the facility sketches submitted to Centralized Application Bureau (CAB). There is no body of water observed. There were 6 resident bedrooms and 2 bathrooms that were observed with adequate lighting. There is an additional room and bathroom that will be for staff use. Facility is equipped with refrigerator, microwave, dishwasher, washer and dryer. There was sufficient supply of plates, glasses, and other utensils. Facility land line telephone was tested and observed operational. Towels, sheets, warm blankets and hygiene products were observed available.

Fire extinguishers that appeared full and were last serviced on 11/1/2023 were observed. First aid kit was observed complete with manual. Flashlights were observed available for use. Licensee/Applicant states all residents will have a call button that is connected to a monitor in the kitchen.

The following were observed during the inspection:
  • missing carbon monoxide
  • missing required posters such as Complaint poster, Personal Rights, Theft and Loss, etc
  • hot water measured at 129.3 degrees Fahrenheit
  • workers were observed in the front yard
  • fence on the right side facing the facility is leaning towards the neighbor's side
  • screen doors/windows/pieces of wood were observed in the side yard

continuation on Lic 809C

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2024
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: WOODLANDS IV
FACILITY NUMBER: 079201325
VISIT DATE: 04/25/2024
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The Licensee/Applicant will send CCL photos of corrections. In regards to the fence, Licensee/applicant states he is in contact with the neighbor and will update CCL.

LPA will inform CAB analyst upon receipt of proof of corrections. Final review of application, and license to be granted by CAB.

Exit interview was conducted, and copy of this report was provided to the applicant.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
LIC809 (FAS) - (06/04)
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