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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601519
Report Date: 09/09/2022
Date Signed: 09/09/2022 03:35:22 PM

Document Has Been Signed on 09/09/2022 03:35 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:LAFAYETTE HEIGHTS RESIDENTIAL CARE IIFACILITY NUMBER:
075601519
ADMINISTRATOR:MOGADAM, JOANNEFACILITY TYPE:
740
ADDRESS:2267 SHANNON LANETELEPHONE:
(925) 979-1200
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY: 6CENSUS: 0DATE:
09/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:JOANNE MOGADAMTIME COMPLETED:
04:00 PM
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On 9/9/22 at 2:00 PM, Licensing Program Analyst (LPA) J. Sampair conducted an infection control annual inspection. Upon arrival, no one was at the facility. LPA called the Licensee, JOANNE MOGADAM, who joined the LPA at the facility within a few minutes. There are currently no residents. They toured the facility inside and outside.

Facility has an infection control plan in place. The designated infection control leader is the administrator.

Exit interview conducted, copy of Appeal Rights, and a copy of this report provided via email
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2022
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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