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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201280
Report Date: 01/30/2024
Date Signed: 01/30/2024 12:54:17 PM

Document Has Been Signed on 01/30/2024 12:54 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:LEAP CARE SERVICES LLCFACILITY NUMBER:
019201280
ADMINISTRATOR:ECHON, RICARDOFACILITY TYPE:
740
ADDRESS:4336 EAST AVENUETELEPHONE:
(925) 223-7791
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY: 6CENSUS: 0DATE:
01/30/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Carl Arcosa, Licensee/ApplicantTIME COMPLETED:
11:45 AM
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On 1/30/2024 at 9:10AM, Licensing Program Analyst (LPA) G. Luk conducted a Pre-licensing Inspection. LPA met with Licensee/Applicant, Carl Arcosa.


LPA toured facility including but not limited to resident's bedrooms, bathrooms, living room, dining area, kitchen, garage, and outdoor area. LPA observed lighting in all rooms. LPA observed facility had some non-perishable food supply. Licensee will purchase additional food supplies once facility is licensed. Carbon monoxide detector was observed in operating condition. First aid kit was complete. Emergency disaster plan was complete.

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

1. Fire extinguisher was observed to be full, but unknown when it was last purchased or serviced. Licensee agreed to either provide a copy of the purchase receipt or have it serviced.

2. Hot water was measured at 131 degrees F in the hallway bathroom sink. Licensee lowered hot water and re-measured hot water at 129.4 degrees F.

3. LPA observed facility's smoke detector was beeping during inspection.



4. LPA observed two bathrooms does not have paper towel holders.

5. LPA observed bedroom #1 and #5 does not have chest of drawers.

(Continue on LI809C...)
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: LEAP CARE SERVICES LLC
FACILITY NUMBER: 019201280
VISIT DATE: 01/30/2024
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6. LPA observed facility does not have mattress pads for all resident beds.

7. LPA observed common bathrooms does not have night lights available.

8. LPA reviewed dementia plan and observed the plan does not address behaviors such as ingestion of toxic chemicals and wandering behaviors.

Licensee/Applicant will submit proof of corrections to CCLD on/before 2/2/2024.

Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024
LIC809 (FAS) - (06/04)
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