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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601538
Report Date: 06/21/2023
Date Signed: 06/21/2023 03:00:42 PM


Document Has Been Signed on 06/21/2023 03:00 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:CARNELIAN IIIFACILITY NUMBER:
075601538
ADMINISTRATOR:GRUTAS, JAYFACILITY TYPE:
740
ADDRESS:2374 WARREN ROADTELEPHONE:
(925) 938-0200
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94595
CAPACITY:6CENSUS: 6DATE:
06/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Staff Member Jio AlonzoTIME COMPLETED:
04:15 PM
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On 06/21/2023 at 12:30 PM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to conduct a Required - 1 Year Inspection. Upon entry, LPA stated the purpose of the visit with Administrator Adlai Grutas. LPA toured facility inside and outside.

The LPA interviewed 3 residents and 3 staff members and reviewed files of 5 staff and 5 residents.

During this inspection, 2 Technical Violations were issued for violation of regulations that do not pose a risk to the health and safety of persons in care.

Exit interview conducted with Staff Member Jio Alonzo. A copy of this report provided via email.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2023
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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