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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 071441125
Report Date: 04/08/2024
Date Signed: 04/08/2024 11:06:09 AM


Document Has Been Signed on 04/08/2024 11:06 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:CASA BLANCA RETIREMENT HOMESFACILITY NUMBER:
071441125
ADMINISTRATOR:SHEILA V MELECIONFACILITY TYPE:
740
ADDRESS:1055 INA DRIVETELEPHONE:
(925) 838-2523
CITY:ALAMOSTATE: CAZIP CODE:
94507
CAPACITY:18CENSUS: 12DATE:
04/08/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator, Shelia MelencionTIME COMPLETED:
11:18 AM
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On 04/08/2024 at 10:00 AM, Licensing Program Analyst (LPA) A. Gomez conducted a Health & Safety inspection as a result of CCLD receiving notification of a fire at the facility. LPA met with Administrator, Shelia Melencion and explained the purpose of the visit.

LPA toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, and outdoor area. Facility sustained fire, water, and smoke damage. The fire started in the kitchen on 4/6/2024 at approximately 8:30PM while staff were frying. Staff yelled fire to notify other staff. Fire extinguisher was used to help put out fire. Fire went into the exhaust vent up into the attic. Fire sprinklers were triggered and 911 was called. Caregivers removed residents from facility as fire was being extinguished. The San Ramon Valley Fire Department arrived to assist with fire being extinguished. The ceiling in kitchen, hallway, and room four were collapsed due to the water damage from fire sprinklers. Kitchen, Living room, and hallways are covered in ash and water. No injuries were sustained. All staff and residents were moved to a safe location.

Residents were moved to other care homes in the surrounding area. Three residents were moved to Good Shepherd of San Ramon. Five residents were moved to Belrose Care Home II. One resident was moved to Welcome Home Senior Residence in Walnut Creek. One resident was moved to Gines Care Home. One resident was moved to Good Shepherd of Danville. One resident was retained by their RP. Administrator informed LPA that they do not plan on re-opening the facility and that families have made arrangements for the residents to be permanently placed at the above facilities.

LPA spoke with Administrator and obtained copies of the Emergency Disaster Plan, Resident Roster, and RP contact information. LPA informed Administrator to notify CCLD in writing of Facility Closure to start the process of closing the facility.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE: 04/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2024
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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