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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200565
Report Date: 01/10/2024
Date Signed: 02/05/2024 05:21:55 PM


Document Has Been Signed on 02/05/2024 05:21 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:COZY FAMILY CAREFACILITY NUMBER:
079200565
ADMINISTRATOR:JI, RUIFACILITY TYPE:
740
ADDRESS:2135 LUPINE ROADTELEPHONE:
(510) 327-4408
CITY:HERCULESSTATE: CAZIP CODE:
94547
CAPACITY:6CENSUS: 6DATE:
01/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:RUI JI ADMINISTRATORTIME COMPLETED:
06:00 PM
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On 01/10/2024 at 2:10PM, Licensing Program Analysts (LPAs) Carol Fowler and Tonica Syess-Gibson conducted an unannounced annual 1-year required inspection. LPAs met with Rui Ji Administrator, The administrator currently holds a certificate (#6040750740) that expires on 08/01/2024. The facility’s fire clearance was approved for six (6)non-ambulatory clients.

LPAs toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, garage, and back yard. The facility consists of seven (7) total bedrooms one (1) room occupied by staff and two (2 ) bathrooms. All indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 71 degrees Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 120.0 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Hand washing poster, paper towel, and soap observed at all hand washing stations. The supply of extra hygiene was available for residents. There is a minimum of 7-days of non-perishables and 2-days of perishables foods.

Smoke detectors/carbon monoxide were in operating condition during visit. Fire extinguisher was last services on 12/15/2023. Fire drill last conducted 01/01/2024. First aid kit was observed to be complete.

Continued on LIC809C.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 01/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2024
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: COZY FAMILY CARE
FACILITY NUMBER: 079200565
VISIT DATE: 01/10/2024
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Continued from LIC809.

Three (3) staff records were reviewed. Four (4) of Six (6) resident records were reviewed and all were found to be complete.


The following forms to be updated and submitted to CCLD by 01/24/202:

Resident Roster
· LIC 308 Designation of Administrative Responsibility
· LIC 309 Administrative Organization
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan (9 pages)
· Liability Insurance


Exit interview conducted. A copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2