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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200620
Report Date: 10/14/2024
Date Signed: 10/14/2024 06:14:39 PM

Document Has Been Signed on 10/14/2024 06:14 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:ROCK OAK VILLAFACILITY NUMBER:
079200620
ADMINISTRATOR/
DIRECTOR:		ANNA MANGLICMOTFACILITY TYPE:
740
ADDRESS:594 ROCK OAK ROADTELEPHONE:
(925) 891-4044
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY: 6CENSUS: 5DATE:
10/14/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Licensee Anna ManglicmotTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
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On 10/14/2024 at approximately 2:00 PM, Licensing Program Analyst (LPA) James Sampair arrived unannounced to conduct a Case Management - Annual Continuation inspection to complete the Required Annual Inspection that was partially completed on 10/3/2024. Upon entry, LPA stated the purpose of the visit to Caregiver Hershiell Leuterio and Caregiver Merwin Untalasco. Licensee Anna Manglicmot arrived at approximately 3:15 PM.

The LPA completed the inspection of facility records. The LPA reviewed the records of 5 residents and 5 staff members.

Administrator will provide LPA copies of the following documents by 10/21/2024:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610E Emergency Disaster Plan (9 pages)
4. $3M Liability Insurance certificate

No citations issued during the inspection.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2024
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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