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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200484
Report Date: 06/27/2024
Date Signed: 06/27/2024 12:49:08 PM


Document Has Been Signed on 06/27/2024 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:SUNOL CREEK MEMORY CAREFACILITY NUMBER:
019200484
ADMINISTRATOR:RAMIREZ, MARGARET DIVINEFACILITY TYPE:
740
ADDRESS:5980 SUNOL BLVDTELEPHONE:
(925) 846-8283
CITY:PLEASANTONSTATE: CAZIP CODE:
94566
CAPACITY:46CENSUS: 41DATE:
06/27/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Harmony Venturelli, Executive Director
Jacqueline Scott Garcia, Human Resources Assistant		TIME COMPLETED:
11:15 AM
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On 6/27/2024 at 10:30AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct Case Management Inspection in regards to the incident report that was received on 6/25/2024. LPA met with Executive Director, Harmony Venturelli and Human Resources Assistant, Jacqueline Scott Garcia. LPA explained the reason for the visit.

Incident report dated 6/25/2024 states that R1 was taken to the doctors due to pain and weakness. R1 had x-rays completed with results of closed fracture.

During visit, LPA interviewed staff and reviewed R1's files. Discharge summary indicated that R1 will follow up with the doctor in one week. After reviewing chart notes, R1 was given PRN medications when experiencing pain.


No deficiencies are being cited on this date.


Exit interview conducted with Jacqueline Scott Garcia. 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: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2024
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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