079200562-12-14-2023-15-AS-AGOZ-CYHRFF-20231214115903

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200562
Report Date: 12/14/2023
Date Signed: 12/14/2023 11:59:09 AM

Document Has Been Signed on 12/14/2023 11:59 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:	GRANNY'S LOVING ANGELS LLC		FACILITY NUMBER:	079200562
ADMINISTRATOR:	BADE, MARIA DARLENE		FACILITY TYPE:	740
ADDRESS:	1000 EL CAPITAN DRIVE		TELEPHONE:	(925) 314-1877
CITY:	DANVILLE	STATE: CA	ZIP CODE:	94526
CAPACITY:	6	CENSUS: 6	DATE:	12/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Joan Tungcul, Caregiver		TIME COMPLETED:	12:20 PM

NARRATIVE

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Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct a 1 Year Annual Required visit on this date starting at 9:00am. Upon arrival, LPAs met with Caregiver, Joan Tungcul and explained the reason of the visit. Administrator was not available during visit.

LPA toured the facility with Caregiver including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 70 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 106.5 degrees F. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable foods and 2-day of perishable foods.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 8/23/2023. Emergency Disaster Plan is current. First aid kit was observed to be complete. Fire drill was last conducted on 6/15/2023.

LPA reviewed 5 staff records. 5 of 5 staff are associated and have current first aid training. LPA reviewed 5 residents records.

Report continues on LIC 809-C

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: GRANNY'S LOVING ANGELS LLC	FACILITY NUMBER: 079200562
	VISIT DATE: 12/14/2023

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 26 27 28 29 30 31 32	Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 12/31/2023: LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Liability Insurance Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

LIC809 (FAS) - (06/04)

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