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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200999
Report Date: 04/09/2021
Date Signed: 04/09/2021 04:40:25 PM

Document Has Been Signed on 04/09/2021 04:40 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:WARM HOUSEFACILITY NUMBER:
019200999
ADMINISTRATOR:DELGADO, CLARAFACILITY TYPE:
740
ADDRESS:7693 DONOHUE DR.TELEPHONE:
(925) 323-8958
CITY:DUBLINSTATE: CAZIP CODE:
94568
CAPACITY: 6CENSUS: 6DATE:
04/09/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Clara DelgadoTIME COMPLETED:
04:45 PM
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On 04/09/2021, Licensing Program Analyst (LPA) Allison O'Hollaren conducted a Tele-visit Pre-Licensing inspection via FaceTime due to Shelter in Place order directed by the Governor. LPA spoke with Administrator Clara Delgado. The facility's fire clearance was approved for six non-ambulatory.

During the tele-Inspection, LPA toured facility with Administrator including but not limited to bedrooms, bathroom, common areas, kitchen, and outdoor area. COVID-19 signage is up in the facility. Resident's bedrooms are fully furnished with bed, dresser, night stand, and chair. Facility currently has six residents. Residents' bathrooms were equipped with grab bars and non-skid mats. LPA observed lighting in all rooms. Medications are stored and locked in a storage cabinet right next to the kitchen area. Smoke detectors and carbon monoxide detectors are interconnected and in operation condition. Hot water temperature was measured 116 degrees F. First aid kit is complete. Indoor and outdoor passageways were free of obstruction. LPA observed that outdoor freezer and refrigerator did not have a temperature gauge and Administrator agreed that outdoor refrigerator and freezer will not store resident food.

LPA conducted Component III with Administrator during Tele-visit. LPA presented Component III Power Point and discussed the regulations embodied in the presentation.

This report will be submitted to the Centralized Application Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required.

Exit interview conducted and a copy of report will be emailed.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Allison O'Hollaren
LICENSING EVALUATOR SIGNATURE: DATE: 04/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/09/2021
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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