<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201153
Report Date: 08/08/2023
Date Signed: 08/08/2023 03:01:27 PM

Document Has Been Signed on 08/08/2023 03:01 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:STRAWBERRY HILL AT GILL PORTFACILITY NUMBER:
079201153
ADMINISTRATOR:WARD, WHITNEYFACILITY TYPE:
740
ADDRESS:2069 GILL PORT LNTELEPHONE:
(415) 710-5169
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY: 6CENSUS: 5DATE:
08/08/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator Whitney WardTIME COMPLETED:
11:30 AM
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
On 08/08/2023 at 10:30 AM, Licensing Program Analyst (LPA) J. Sampair arrived at facility for Required Annual Inspection. Upon arrival, LPA stated purpose of the inspection to Administrator (ADM) Whitney Ward.
During inspection, the LPA and ADM discussed the initial incident, follow-up care, and current health status of residents R1 and R2 after their return from the hospital.

Exit interview conducted with ADM. A copy of this report provided for ADM by LPA via email.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2023
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 1