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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200629
Report Date: 06/22/2023
Date Signed: 06/22/2023 04:48:26 PM


Document Has Been Signed on 06/22/2023 04:48 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:BAYBERRY HOMEFACILITY NUMBER:
079200629
ADMINISTRATOR:FROILAN ABESAMISFACILITY TYPE:
740
ADDRESS:3526 BAYBERRY DRIVETELEPHONE:
(925) 279-1132
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:4CENSUS: 4DATE:
06/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Administrator Froilan AbesamisTIME COMPLETED:
05:00 PM
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On 06/22/2023 at 01:30 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 (ADM) Froilan Abesamis. ADM and LPA then toured the facility inside and outside.

The LPA conducted or attempted to conduct interviews of 2 residents and did successfully interview 2 staff members. LPA reviewed files of 5 staff and 4 residents.

During this inspection, 1 Technical Violation was issued for a violation that did not pose a risk to the health and safety of persons in care.

Exit interview conducted with ADM. A copy of this report provided by LPA via email.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2023
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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