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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600722
Report Date: 12/02/2022
Date Signed: 12/02/2022 10:24:41 AM


Document Has Been Signed on 12/02/2022 10:24 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:A HOME OF OUR OWN IIFACILITY NUMBER:
015600722
ADMINISTRATOR:FEKETE, EMILYFACILITY TYPE:
740
ADDRESS:2162 HAMPTON ROADTELEPHONE:
(925) 292-4848
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY:2CENSUS: 0DATE:
12/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Emily Fekete, Licensee/AdministratorTIME COMPLETED:
10:30 AM
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On 12/2/2022 at 9:00AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct an Infection Control Inspection. LPA rang the door bell a couple times and knocked on the door with no response. LPA observed two car in the driveway. LPA called licensee, Emily Fekete and was able to let LPA inside around 9:20AM.

LPA was informed facility had no residents since 2006. LPA toured facility including but not limited to bedroom, bathrooms, kitchen, common areas, and outdoor area. LPA observed facility had grab bars and non-skid mats.

Facility had a pool without a fence. Licensee understands that a 5 ft fence will be put up prior to admitting residents. LPA observed the front door has a dead bolt with key lock from the inside. Licensee understands and will change the dead bolt to a turning knob prior to admitting residents.

No deficiencies are being cited on this date.

Exit interview conducted. A copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2022
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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