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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700977
Report Date: 02/24/2023
Date Signed: 02/24/2023 02:54:16 PM

Document Has Been Signed on 02/24/2023 02:54 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:MONTCLAIR HOMEFACILITY NUMBER:
502700977
ADMINISTRATOR:KALU, EKE PATRICKFACILITY TYPE:
735
ADDRESS:1413 MONTCLAIR DRIVETELEPHONE:
(925) 998-1037
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY: 4CENSUS: 3DATE:
02/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Administrator Patrick Kalu TIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct an annual/required visit. LPA met with Administrator Patrick Kalu and explained the purpose of the visit. Census 3
LPA Lund & Administrator Patrick Kalu toured/inspected the facility. LPA inspected the dining area, living area, and all other areas intended for client use. LPA observed to be furnished and maintained in compliance at this time.
The Facility had a Medication closet (locked) were medication will be stored. First aid kit was observed in the Medication closet to be present and contained all required components at this time.
A tour of the (4) private resident bedrooms, was conducted. Furnishings intended for use by the residents were observed to meet the needs of the residents at this time. The Facility also had an office for staff. The facility also had three restrooms of which one was in the master bedroom. The contains a sufficient supply of towels and linens able to meet the needs of the clients at this time.
A tour of the exterior grounds was conducted. A review of the facility perimeter fence, side gates, and walkways were observed to be maintained in compliance at this time. The facility has two fire extinguisher that expire on 3/1/2023 and had a working telephone.
There were no deficiencies found during today’s visit. Exit interview held with Administrator Patrick Kalu and a copy of report left.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2023
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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