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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601437
Report Date: 07/24/2023
Date Signed: 07/24/2023 12:49:25 PM


Document Has Been Signed on 07/24/2023 12:49 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:AN OAK GROVE MANORFACILITY NUMBER:
075601437
ADMINISTRATOR:VELARDE-BAENS, SHIRLEY A.FACILITY TYPE:
740
ADDRESS:2801 OAK GROVE ROADTELEPHONE:
(925) 926-0405
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:6CENSUS: 5DATE:
07/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Shirley Velarde-BaensTIME COMPLETED:
01:15 PM
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On 07/24/2023 at 09:35 AM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced at facility for required annual inspection. LPA was greeted by staff member Michael David. Licensee Shirley Velarde-Baens arrived at 10:00 AM.

During the Inspection, LPA observed that the facility has a sufficient supply of food: 2 days perishable and 7 days nonperishable. A comfortable inside temperature of 75 was maintained. The facility was well maintained, clean, and clutter-free inside and outside.

LPA interviewed 2 residents and 2 staff members, and reviewed the records for 5 residents and 5 staff members.

No citations issued during visit.

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: 07/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2023
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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