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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600722
Report Date: 12/06/2023
Date Signed: 12/06/2023 11:49:07 AM


Document Has Been Signed on 12/06/2023 11:49 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:
12/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Emily Fekete, Administrator/LicenseeTIME COMPLETED:
12:00 PM
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On 12/6/2023 at 9:00AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with Administrator/Licensee, Emily Fekete and explained the purpose of the visit. The facility’s fire clearance was approved for 2 non-ambulatory residents.

LPA was informed facility had no residents. LPA toured facility including but not limited to bedroom, bathrooms, kitchen, common areas, and outdoor area. Smoke and carbon monoxide detectors were observed. Fire extinguisher was observed to be full. Facility has some nonperishable and perishable foods available. Licensee will obtain additional food prior to admitting residents. LPA observed grab bars and non-skid mat in the bathroom. First Aid kit is complete. The facility has a written emergency disaster plan.

LPA reviewed administrator's file.

Facility has a pool without a fence. Licensee understands that a 5 ft fence will be put up 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: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2023
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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