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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201334
Report Date: 04/12/2024
Date Signed: 04/16/2024 10:34:39 AM

Document Has Been Signed on 04/16/2024 10:34 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:PVS ASSISTED LIVING INCFACILITY NUMBER:
079201334
ADMINISTRATOR/
DIRECTOR:		SCATTOLIN, PAULFACILITY TYPE:
735
ADDRESS:150 S 39TH STTELEPHONE:
(925) 705-3020
CITY:RICHMONDSTATE: CAZIP CODE:
94804
CAPACITY: 4CENSUS: DATE:
04/12/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Abril Juarez, Direct Support ProfessionalTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
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On 4/12/2024 at 9:55AM Licensing Program Analysts (LPAs) L. Hall and L. Holmes conducted an continued unannounced pre-licensing inspection and met with Abril Juarez, Direct Support. LPA L. Hall spoke with Administrator, Paul Scattolin, via telephone.

LPAs toured the bedrooms to confirm all clients are residing inside the facility. There were not any clients residing in the additional unit located in the back yard.

LPA received approval from Licensing Program Manager (LPM), H. Humpal to waive Component III.

No issues noted during inspection. LPAs observed that facility is 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 and a copy of this report provided
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 04/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/16/2024
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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