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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201082
Report Date: 01/04/2022
Date Signed: 01/04/2022 12:34:02 PM

Document Has Been Signed on 01/04/2022 12:34 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:GRACE HOME CARE - MEADOWLARKFACILITY NUMBER:
019201082
ADMINISTRATOR:DEL ROSARIO, GRACEFACILITY TYPE:
740
ADDRESS:538 MEADOWLARK STREETTELEPHONE:
(510) 543-8013
CITY:LIVERMORESTATE: CAZIP CODE:
94551
CAPACITY: 6CENSUS: 4DATE:
01/04/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Grace Del Rosario, Licensee/ AdministratorTIME 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 1/4/2022 at 9:25AM, Licensing Program Analysts (LPAs) G. Luk and G. Clark conducted an unannounced Pre-licensing Inspection. LPAs met with staff, Amalia Saptang and Janet Quines. Licensee/Administrator, Grace Del Rosario arrived 2 hours later.

LPAs inspected the facility inside and out including but not limited to bedrooms, bathrooms, dining room, kitchen, living room, garage, and outdoor area. Hot water temperature was measured at 110 degrees F. No bodies of water observed. Disaster plan was completed on 3/2/2021. Home is clean and well ventilated with appropriate lighting. LPAs observed liability insurance.

Fire extinguisher was observed to be full and purchased on 6/22/2021. Smoke and carbon monoxide detectors were observed. First aid kit was complete. Facility has a 7-day non-perishable and 2-day perishable food supply.

The following will need to be completed before recommending licensure to Centralized Application Bureau (CAB):

1. LPAs observed that facility did not have a plan of operations at the facility. Licensee will send the plan of operations to LPAs and maintain a copy at the facility.


Licensee/applicant will submit proof of corrections to CCL on/before 1/10/2022.

LPAs waived Component III as Licensee/Administrator have been in this position for 15 years and have other licensed facilities. LPAs provided a copy of the Component III for review.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 01/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/04/2022
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