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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200484
Report Date: 01/10/2023
Date Signed: 01/10/2023 05:47:46 PM


Document Has Been Signed on 01/10/2023 05:47 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:SUNOL CREEK MEMORY CAREFACILITY NUMBER:
019200484
ADMINISTRATOR:ROSE, JESSICAFACILITY TYPE:
740
ADDRESS:5980 SUNOL BLVDTELEPHONE:
(925) 846-8283
CITY:PLEASANTONSTATE: CAZIP CODE:
94566
CAPACITY:46CENSUS: 32DATE:
01/10/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Divine Ramirez, Interim Executive DirectorTIME COMPLETED:
06:00 PM
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On 1/10/2023 at 3:15PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit regarding the incident report received on 1/3/2023.
LPA met with Interim Executive Director, Divine Ramirez and informed her the reason for the visit.

Incident report states that on 12/31/2022 Fire Marshal was on site due to the flooding on the south side parking lot caused by a storm water line. There was minor flooding and water damaged that was centralized to the south side of the facility. Affecting rooms include room 101-108. Residents were escorted to the north side of the facility and moved to different accommodations. All residents were fine and no injuries.

During visit, LPA toured the rooms that the residents were relocated and observed the residents were doing well. LPA obtained temporary relocation sites and a list of residents. LPA was informed that 8 rooms were affected and 13 residents were relocated to unoccupied rooms in the facility. Interim Executive Director will update LPA once repair plans have been made.

LPA requested flood mitigation plan with repair information and a flood prevention plan.

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: 01/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2023
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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