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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701281
Report Date: 10/26/2023
Date Signed: 10/27/2023 11:44:55 AM

Document Has Been Signed on 10/27/2023 11:44 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:EMPIRE HOME INCFACILITY NUMBER:
392701281
ADMINISTRATOR:LEGARDA, MARISSAFACILITY TYPE:
735
ADDRESS:290 WEST WILLOW CREEK DRIVETELEPHONE:
(650) 892-9264
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY: 4CENSUS: 0DATE:
10/26/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Marissa LegardaTIME COMPLETED:
01:00 PM
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On 10/26/2023, Licensing Program Analyst (LPA) Arielle Pascua arrived announced to conduct a Pre-Licensing visit. LPA was greeted by applicants, Marissa Legarda, Rudy Golalao, and Muhammed Shamin and explained the purpose of the visit. The purpose of this visit was to conduct a Pre-Licensing Visit.
This facility will be licensed to hold 4 residents, of which 2 may be non-ambulatory in bedrooms #1 and #2. This facility is also awaiting vendorization from Valley Mountain Regional Center and will accept and hold Level 4I residents.

A tour of the facility was conducted. Smoke detectors and carbon monoxide detectors were tested and are in good repair.

A tour of the kitchen area was toured. A review of food supply was conducted to ensure a 2 day perishable and 7 day non-perishable food supply was available. This facility will have a locked medication cabinet located in the kitchen. A first aid kit was observed and had all the required components. Fire extinguisher was located in kitchen and was serviced on 03/31/2023 by the local fire company, Coast Fire Equipment Co.
A tour of the family room was conducted. Furniture and furnishings were observed to be in good repair.
A tour of the backyard was conducted with no hazards present. Perimeter gate was observed to be in good repair.
A tour of garage was conducted. A washer and dryer was identified. Detergent, toxins and other cleaning supplies were observed to be locked and made inaccessible.
A tour of the resident bedrooms were conducted. Furniture and furnishing were observed to meet the residents needs.
A linen closet was located in hallway and was observed to have a sufficient amount of linen to meet the residents needs at this time.
A tour of two resident restrooms were toured. Hot water temperature was taken to ensure that it was in within 105-120 degrees.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/26/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: EMPIRE HOME INC
FACILITY NUMBER: 392701281
VISIT DATE: 10/26/2023
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Common areas were toured. Living room, dining area and all other areas intended for resident use were observed to be furnished and in compliance at this time.

This facility has been observed to be in compliance at this time.
There were no deficiencies observed during the course of this Pre-licensing visit.

Applicant has already conducted Comp I and Comp II.
Comp III will be waived at this time.

Exit Interview.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023
LIC809 (FAS) - (06/04)
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