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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201393
Report Date: 08/13/2024
Date Signed: 08/13/2024 11:31:03 AM

Document Has Been Signed on 08/13/2024 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:BLUEROCK HOMEFACILITY NUMBER:
079201393
ADMINISTRATOR/
DIRECTOR:		PADAYAO, NANETFACILITY TYPE:
735
ADDRESS:928 BLUEROCK DRTELEPHONE:
(925) 848-7423
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 6CENSUS: 0DATE:
08/13/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:05 AM
MET WITH:Nanet Padayao, Administrator/LicenseeTIME VISIT/
INSPECTION COMPLETED:
10:55 AM
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On 8/13/2024 at 10:05AM, Licensing Program Analyst (LPA) L. Hall conducted an announced pre-licensing inspection. LPA met with Nanet Padayao, Administrator/Licensee. The facility has an approved fire safety clearance for six (6) ambulatory clients.

LPA inspected the facility inside and out including but not limited to the bedrooms, bathrooms, common living areas, kitchen, garage, back yard. The facility has a total of four (4) bedrooms and two and one-half (2 1/2) bathrooms. No bodies of water observed. There is sufficient lighting around the facility. Clients rooms are equipped with the proper furniture, bedding, and lighting. Passageways and hallways are free of obstruction. Locked cabinets available to store medications, toxins and sharps. Hot water temperature is measured at 110.4 degrees Fahrenheit in shared clients' bathroom. Fire extinguisher was last purchased on 8/27/2023. 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. Facility inspection matches the sketch that was provided.

No Issues were noted during inspection. LPA 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 with Administrator and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/13/2024
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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