<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601315
Report Date: 01/14/2025
Date Signed: 01/14/2025 10:12:27 AM

Document Has Been Signed on 01/14/2025 10:12 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:BLACKHAWK SENIOR RESIDENTIAL CAREFACILITY NUMBER:
075601315
ADMINISTRATOR/
DIRECTOR:		PETITI, NORAFACILITY TYPE:
740
ADDRESS:209 FARM HILL COURTTELEPHONE:
(925) 820-8783
CITY:DANVILLESTATE: CAZIP CODE:
94526
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 1DATE:
01/14/2025
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:10 AM
MET WITH:Backup Administrator, Adoracion De Leon AcampoTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 1/14/2025 at 8:10 AM, Licensing Program Analyst (LPA) A. Gomez conducted a Health & Safety inspection as a result of the department receiving notice that the licensee passed away. LPA met with Backup Administrator, Adoracion De Leon and explained the purpose of the visit.

LPA toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, and outdoor area. Hot water temperature was measured at 107.4 degrees F in the hallway bathroom. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Facility grocery shops on a weekly basis. Refrigerator temperature was observed at 40 degrees F. Resident's medications were kept locked in cabinet. Smoke detectors and carbon monoxide detector observe. First-aid kit was complete. Fire extinguisher was observed to last purchased December 2023. Pool observed to be locked and secured. Indoor and outdoor passageways are free of obstruction.

Facility currently has one (1) resident who is scheduled to move out by 2/15/2025. There were two (2) caregivers on duty at the time of the inspection All staff agreed to stay working at the facility until the resident relocates. LPA spoke with next of kin over the phone who stated that they do not wish to be involved with the business of the facility and is allowing Backup Administrator, Adoracion De Leon to make the final decisions relating to the facility. Backup Administrator, Adoracion De Leon states that the facility will be permanently closed effective 2/15/2025 and will surrender the licence.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
Yvonne Flores-LariosTELEPHONE: (510) -28-0517
Alona GomezTELEPHONE: 510-239-1306
DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2025
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 1