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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601298
Report Date: 02/09/2024
Date Signed: 02/09/2024 12:49:55 PM


Document Has Been Signed on 02/09/2024 12:49 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:JASMINE COURTFACILITY NUMBER:
015601298
ADMINISTRATOR:BRANDIE KELBERFACILITY TYPE:
740
ADDRESS:5508 JASMINE COURTTELEPHONE:
(510) 586-0845
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94552
CAPACITY:4CENSUS: 4DATE:
02/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:BRANDIE KELBER, Administrator TIME COMPLETED:
01:15 PM
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On 2/9/2024 at 9:00 AM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator; BRANDIE KELBER explained the purpose of the visit.

LPA toured facility with Brandie including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 4 total bedrooms which 4 bedrooms are occupied by the residents and 0 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 68 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 110 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is 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 detectors were in operating condition during visit. Fire extinguisher was last serviced on 07/12/2023. Emergency Disaster Plan was last posted on 1/1/2024. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 01/01/2024.

LPA reviewed 4 residents records. LPA reviewed 2 staff records and 2 of 2 have current first aid training and associated to the facility.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided via email.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2024
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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