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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601419
Report Date: 08/10/2023
Date Signed: 08/10/2023 05:37:17 PM


Document Has Been Signed on 08/10/2023 05:37 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:HALCYON CARE HOMEFACILITY NUMBER:
075601419
ADMINISTRATOR:PHAN, MARIVIC V.FACILITY TYPE:
740
ADDRESS:1024 MT. VIEW BLVD.TELEPHONE:
(415) 244-0985
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94596
CAPACITY:6CENSUS: 4DATE:
08/10/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:25 PM
MET WITH:Caregiver Michael PhanTIME COMPLETED:
05:45 PM
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On 08/10/2023 at 4:25 PM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to conduct case management visit concerning death of resident R1 on 08/07/2023 and the Death Report dated 08/08/2023 submitted to the Department. Upon entry, LPA stated the purpose of the visit to caregiver Michael Phan.

LPA interviewed Mr. Phan on the health history of R1. The detailed information he provided as well as the records the LPA reviewed were fully in accordance with the 08/08/2023 Death Report.

No citations issued.

Exit interview was conducted with Mr. Phan. 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: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2023
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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