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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200738
Report Date: 01/03/2025
Date Signed: 01/03/2025 02:45:20 PM

Document Has Been Signed on 01/03/2025 02:45 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:PLEASANT HILL VILLA HOME CARE 2FACILITY NUMBER:
079200738
ADMINISTRATOR/
DIRECTOR:		MAGAT, GLICERIAFACILITY TYPE:
740
ADDRESS:2968 BONNIE LANETELEPHONE:
(408) 933-8663
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
01/03/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Joy Dela Cueva, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On 01/03/2025 at 12:15 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Caregiver, Leonora Gabatino and explained the purpose of the visit. Leonora phoned the Administrator, Joy Dela Cueva to inform. The administrator arrived shortly after. The facility’s fire clearance was approved for capacity six (6) non-ambulatory. Hospice waiver approved for three (3) residents. Administrator certificate #7004869740 expires 06/25/2026.

LPA toured facility with Leonora including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of seven (7) total bedrooms which six (6) bedrooms are occupied by the residents and one (1) bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water 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 112.3 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents.

Smoke and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 08/21/2024. Emergency Disaster Plan was last posted on 01/30/2024. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 12/10/2024.

LIC809-C Continued...
Bennett FongTELEPHONE: (510) 725-7919
Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
DATE: 01/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/03/2025
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: PLEASANT HILL VILLA HOME CARE 2
FACILITY NUMBER: 079200738
VISIT DATE: 01/03/2025
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LIC809-C (Page 2)

LPA reviewed six (6) residents records. LPA reviewed eight (8) staff records and 8 of 8 have current first aid training and associated to the facility.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 01/10/2025:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
Updated LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan - Reviewed
Liability Insurance
Current Administrator’s Certificate - Reviewed

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2025
LIC809 (FAS) - (06/04)
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