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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201061
Report Date: 05/14/2021
Date Signed: 05/14/2021 02:11:14 PM

Document Has Been Signed on 05/14/2021 02:11 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:CROW CANYON RESIDENTIAL CARE IIIFACILITY NUMBER:
079201061
ADMINISTRATOR:YU, RUFFYFACILITY TYPE:
740
ADDRESS:2254 DOVER WAYTELEPHONE:
(925) 732-2691
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY: 6CENSUS: 0DATE:
05/14/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Ruffy Yu, LicenseeTIME COMPLETED:
01:20 PM
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On 05//14/2021 at 12:10pm, Licensing Program Analyst (LPA) L. Hall conducted an announced pre-licensing inspection and met with Ruffy Yu, Licensee.

LPA along with the Licensee toured the facility inside and out including but not limited to the bedrooms, bathrooms, common living areas, kitchen, garage and backyard. The facility has a total of four (4) bedrooms and two (2) bathrooms. There is sufficient lighting around the facility. Clients rooms are equipped with the proper furniture, bedding, and lighting. Bathrooms showers/tubs were equipped with grab bars and non- skid mats. Passageways and hallways are free of obstruction. LPA observed a locked kitchen cabinet that will store medications. Thermometer in hallway showed temperature as 68 degrees F. Hot water temperature is measured at 122.0 degrees Fahrenheit. Fire extinguisher was last serviced on 09/10/2020. There is a minimum of 7-day non-perishables and 2-day perishables foods. Carbon monoxide and smoke detectors were in working condition.

Prior to licensure, the following shall be corrected and picture sent to CCL by 05/21/2021.
  • Completed first aid kit.
  • Washer and dryer installed.
  • A locked cabinet that would store sharps and toxins.
  • All debris removed from garage and backyard.
  • Place with all required documentation posted.


Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 05/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/14/2021
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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