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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201334
Report Date: 02/27/2024
Date Signed: 02/27/2024 04:54:47 PM

Document Has Been Signed on 02/27/2024 04:54 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:PVS ASSISTED LIVING INCFACILITY NUMBER:
079201334
ADMINISTRATOR:SCATTOLIN, PAULFACILITY TYPE:
735
ADDRESS:150 S 39TH STTELEPHONE:
(925) 705-3020
CITY:RICHMONDSTATE: CAZIP CODE:
94804
CAPACITY: 4CENSUS: 4DATE:
02/27/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Sara Reyes, Direct Support ProfessionalTIME COMPLETED:
04:10 PM
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On 2/27/2024 at 2:00pm, Licensing Program Analyst (LPA) L. Hall conducted an unannounced pre-licensing inspection (facility is in operation and changing ownership). LPA met with Sara Reyes, Direct Support Professional. The facility has an approved fire safety clearance for four (4) ambulatory clients. During inspection LPA observed one (1) client in a bedroom and all other clients were in the community.

LPA inspected the facility inside and out including but not limited to the bedrooms, bathrooms, common living areas, kitchen, back yard. The facility has a total of four (2) bedrooms and two (2) bathrooms. One bedroom (downstairs) is occupied by staff. No bodies of water observed. There is sufficient lighting around the facility. Clients rooms are equipped with the proper furniture, bedding, and lighting. Bathrooms showers/tubs were equipped with non skid mats. Passageways and hallways are free of obstruction. Locked cabinets available to store medications, toxins and sharps. Hot water temperature is measured at 86.5 degrees Fahrenheit in shared clients' bathroom and 115.5 in kitchen. Fire extinguisher was last serviced on 9/26/2023. There is a minimum of 7-day non-perishables and 2-day perishables foods. First Aid kit was complete. Carbon monoxide and smoke detectors present. Fire drill last conducted 1/19/2024.

Issues were noted during inspection. LPAs observed that facility is not ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAU. Additional requirements may still be required.

Exit interview conducted with Administrator and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/27/2024
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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