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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600012
Report Date: 08/23/2023
Date Signed: 08/23/2023 01:14:52 PM


Document Has Been Signed on 08/23/2023 01:14 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:WILLOW GLEN RESIDENCEFACILITY NUMBER:
075600012
ADMINISTRATOR:VILLAREAL, LEVIFACILITY TYPE:
740
ADDRESS:2040 MENDOCINO DRIVETELEPHONE:
(925) 458-5057
CITY:BAY POINTSTATE: CAZIP CODE:
94565
CAPACITY:5CENSUS: 0DATE:
08/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Levi Villareal, LicenseeTIME COMPLETED:
01:20 PM
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On 8/23/2023 at 12:05PM, Licensing Program Analysts (LPAs) L. Hall and L. Alexander conducted an unannounced 1-Year Required inspection. LPAs met with Levi Villareal, Administrator, and explained the purpose of the visit. The Administrator certificate is pending and expired 3/26/2023. Facility does not have any residents at this time.

LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard. The facility consists of four (4) bedrooms and two (2) bathrooms. No bodies of water was observed. A comfortable temperature is maintained at 76 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 109.7 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 08/23/2022. First aid kit was observed to be complete.

Continued on LIC809.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: WILLOW GLEN RESIDENCE
FACILITY NUMBER: 075600012
VISIT DATE: 08/23/2023
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Continued from LIC809.

LPA did not review any staff files.

LPA requested the following documents to be submitted to CCLD by 8/30/2023.
  • Resident Roster
  • LIC 308 Designation of Administrative Responsibility
  • LIC 309 Administrative Organization
  • LIC 500 Personnel Report
  • LIC 610E Emergency Disaster Plan (9 pages)
  • Liability Insurance


No deficiencies cited during this visit.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2