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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201334
Report Date: 03/11/2025
Date Signed: 03/11/2025 02:53:16 PM

Document Has Been Signed on 03/11/2025 02:53 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/
DIRECTOR:
SCATTOLIN, PAULFACILITY TYPE:
735
ADDRESS:150 S 39TH STTELEPHONE:
(925) 705-3020
CITY:RICHMONDSTATE: CAZIP CODE:
94804
CAPACITY: 4CENSUS: 3DATE:
03/11/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:10 PM
MET WITH:Abriel Juarez, Care StaffTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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On 03/11/2025 starting at 12:10 PM, Licensing Program Analyst (LPAs) L. Holmes and Y. Brown arrived unannounced to conduct a Required 1-Year Inspection. LPAs met with Abril Juarez, Care Staff (S1) and explained the purpose of the visit. Administrator was not available during inspection, permission was given for S1 to sign the document.

LPAs toured facility with S1 including but not limited to bedrooms, bathrooms, and there is one ADU in the backyard. All outdoor and indoor passageways were kept free of obstruction. There are no bodies of water observed. A comfortable temperature of 70 degrees was maintained at the facility. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients; clients bathroom needs non-skid mats. There was a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 09/24/2024. Emergency Disaster Plan was posted. First aid kit complete. Emergency disaster drill was last conducted on 02/2025. Facility has infection control signage throughout, and PPE centrally stored and easily accessible for staff within the facility.
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LPAs reviewed 3 client records and 2 staff records. Clients SPV forms need to be signed by ADM and clients.
Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 03/18/2025:
LIC 308 Designation of Administrative Responsibility
LIC 610 Update with local shelter and one outside of the area
LIC 500 Personnel Report
Liability Insurance
No deficiencies cited during visit. Exit interview conducted and a copy of this report provided to S1.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2025
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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