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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201195
Report Date: 11/04/2022
Date Signed: 11/04/2022 12:20:42 PM

Document Has Been Signed on 11/04/2022 12:20 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:SCARLET HOUSEFACILITY NUMBER:
079201195
ADMINISTRATOR:WHITE, RACHELFACILITY TYPE:
740
ADDRESS:5111 PAUL SCARLET DRIVETELEPHONE:
(650) 580-3239
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY: 6CENSUS: 3DATE:
11/04/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Carrene Coronel ,CargiverTIME COMPLETED:
12:35 PM
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On 11/04/202 at 9:40 AM, Licensing Program Analyst (LPA) P. Watson arrived unannounced to conduct Pre-Licensing inspection. LPA met with Cargiver, Carrene Coronel and explained the purpose of the visit. LPA spoke with Administrator, Rachel White on the phone. Administrator was unable to be at the facility and allowed Carrene to sign for them. The facility had a change in ownership and currently has 3 residents.

LPA toured facility with including but not limited to 6 bedrooms, 3 bathrooms, kitchen, common areas and backyard. All bedrooms except for Bedroom 4 and living rooms were equipped with the proper furniture. Bathrooms were equipped with grab bars and non-skid mats. Linens and hygiene supplies were observed inside a cabinet. There is sufficient lighting throughout facility. Room temperature was maintained at 77 degrees F and hot water temperature was maintained at 117 degrees F. First-aid kit was observed to be not complete. Smoke detectors and carbon monoxide were operational. Fire extinguisher was last serviced on 09/20/2022.

Prior to licensure, the following shall be corrected and faxed to CCL by 11/14/2022

-Bedroom 4 needs to be furnished with a bed, complete bedding, and a chair.
-Obtain a completed first aid kit

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Paris Watson
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2022
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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