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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601495
Report Date: 10/15/2024
Date Signed: 10/15/2024 05:04:11 PM


Document Has Been Signed on 10/15/2024 05:04 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:J. CABRAL ELDER CARE,LLCFACILITY NUMBER:
075601495
ADMINISTRATOR:CABRAL, MARIA JOCELYN SFACILITY TYPE:
740
ADDRESS:5500 KELROSE COURTTELEPHONE:
(925) 673-1237
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY:6CENSUS: 6DATE:
10/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Roan Tiamzon, CaregiverTIME COMPLETED:
05:15 PM
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On 10/15/2024 at 3:30pm, Licensing Program Analyst (LPA) L. Hall conducted an unannounced annual required inspection. LPA met with Administrator, Roan Tiamzon, Caregiver. Administrator, Maria Cabral, arrived at 4:05pm, and explained the purpose of the visit. The Administrator holds a certificate 7003164740 which expires on 1/2/2026. The facility’s fire clearance is approved for five (5) non-ambulatory, one (1) bedridden and a hospice waiver for three (3).

LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard. The facility consists of five (5) bedrooms and two and one-half (2 1/2) bathrooms. One (1) bedroom is occupied by staff. No bodies of water was observed. A comfortable temperature is maintained at 72 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 110.0 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 purchased on 10/1/2024. Emergency Disaster Plan was last posted on 10/1/2024. First aid kit was observed to be complete. Fire drill was last conducted on 10/6/2024.

Continued on LIC809.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2024
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: J. CABRAL ELDER CARE,LLC
FACILITY NUMBER: 075601495
VISIT DATE: 10/15/2024
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Continued from LIC809.

LPA reviewed four (4) staff and all six (6) residents files all were current and complete.

LPA requested the following documents to be submitted to CCLD by 10/22/2024.
  • LIC 308 Designation of Administrative Responsibility
  • LIC 500 Personnel Report
  • LIC 610E Emergency Disaster Plan (last page)
  • Liability Insurance


No deficiencies cited during 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: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2