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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201061
Report Date: 05/24/2024
Date Signed: 05/24/2024 03:35:29 PM

Document Has Been Signed on 05/24/2024 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:CROW CANYON RESIDENTIAL CARE IIIFACILITY NUMBER:
079201061
ADMINISTRATOR/
DIRECTOR:		YU, RUFFYFACILITY TYPE:
740
ADDRESS:2254 DOVER WAYTELEPHONE:
(925) 732-2691
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY: 6CENSUS: 6DATE:
05/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:40 PM
MET WITH:Loida Tamayo, CaregiverTIME VISIT/
INSPECTION COMPLETED:
03:50 PM
NARRATIVE
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On 5/24/2024 at 1:40pm, Licensing Program Analyst (LPA) L. Hall conducted an unannounced 1-Year Required inspection. LPA met with Caregiver, Loida Tamayo and explained the purpose of the visit. The Administrator currently holds a certificate (#7034377740) that expires on 12/2/2025. The facility’s fire clearance was approved for six (6) ambulatory residents.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of four (4) bedrooms and two (2) bathrooms. One (1) bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. A comfortable temperature is maintained at 71 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 110.3 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods.

Smoke detectors/ carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 12/01/2023. Emergency Disaster Plan was last reviewed on 5/18/2024. First aid kit was observed to be complete. Fire drill was last conducted on 4/27/2024.

Continued on LIC809.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2024
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: CROW CANYON RESIDENTIAL CARE III
FACILITY NUMBER: 079201061
VISIT DATE: 05/24/2024
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Continued from LIC809.

Three (3) staff records were reviewed, current and complete. All six (6) resident records were reviewed, current, and complete. LPA reviewed P & I.

LPA requested the following documents to be submitted to CCLD by 5/31/2024.
  • LIC 308 Designation of Administrative Responsibility
  • LIC 309 Administrative Organization
  • LIC 500 Personnel Report
  • LIC 610E Emergency Disaster Plan (last page)
  • Liability Insurance
  • Surety Bond

No deficiencies cited during visit.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2024
LIC809 (FAS) - (06/04)
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