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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601459
Report Date: 07/08/2021
Date Signed: 07/08/2021 11:39:00 AM

Document Has Been Signed on 07/08/2021 11:39 AM - 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:BALTIC SEA MANORFACILITY NUMBER:
075601459
ADMINISTRATOR:PRICE, VIVIANFACILITY TYPE:
740
ADDRESS:311 BALTIC SEA COURTTELEPHONE:
(925) 783-0988
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY: 6CENSUS: 6DATE:
07/08/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Emmanuel Salas, CaregiverTIME COMPLETED:
11:45 AM
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On 7/8/2021 at 11:25AM, Licensing Program Analysts (LPAs) L. Hall and C. Fowler arrived unannounced to conduct an health and safety check as a result of department receiving a priority 1 complaint.. LPAs met with Caregiver, Emmanuel Salas and informed her the reason for visit.

Upon arrival, LPAs observed total of 1 staff and 6 residents at the facility.

LPAs toured facility including but not limited to bedrooms, bathroom, and common areas. Residents in care appear to be safe and there are no imminent health/safety concerns on today's date. Facility is noted to be clean and in good repair on today's date. Snacks were being served to some residents during LPAs visit. Facility is maintained at a comfortable temperature for the clients in care.

No deficiencies were cited today.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 07/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/08/2021
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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