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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600206
Report Date: 10/02/2023
Date Signed: 10/02/2023 01:02:43 PM


Document Has Been Signed on 10/02/2023 01:02 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:A & A CARE HOME IFACILITY NUMBER:
075600206
ADMINISTRATOR:BORJA, AMYFACILITY TYPE:
740
ADDRESS:521 FENWAY DRIVETELEPHONE:
(925) 210-0808
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:6CENSUS: 5DATE:
10/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Amy BorjaTIME COMPLETED:
01:30 PM
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On 10/02/22 at 9:30 AM, Licensing Program Analyst (LPA) J. Sampair conducted an unannounced annual inspection. Upon arrival, LPA explained the purpose of the visit to Caregivers Anne Turno and Homer Baliton. Licensee Amy Borja arrived at approximately 10:15 AM.

During the Inspection, the LPA inspected the facility inside and outside. LPA interviewed 2 staff members and 2 residents, and reviewed the records of 5 staff and 5 residents.

LPA observed that the facility has a sufficient supply of food: 2 days perishable and 7 days nonperishable. A comfortable inside temperature of 70.4 degrees F was maintained. The facility was clean and the staff attentive to residents' needs.

No citations issued.

Exit interview conducted with Licensee and a copy of this report was provided via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 10/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2023
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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