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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201209
Report Date: 05/01/2023
Date Signed: 05/01/2023 11:04:58 AM

Document Has Been Signed on 05/01/2023 11:04 AM - 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:GRAND OAK MANOR SUITE LLCFACILITY NUMBER:
079201209
ADMINISTRATOR:RAMOS, DIGNAFACILITY TYPE:
740
ADDRESS:945 FANED WAYTELEPHONE:
(925) 364-0882
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY: 4CENSUS: DATE:
05/01/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:53 AM
MET WITH:Digna Ramos, Licensee TIME COMPLETED:
11:15 AM
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On 05/01/2023 at 8:53 am Licensing Program Analyst (LPA) Jill Clancy-Czuleger, conducted an announced pre-licensing inspection. License application is for (4) total capacity, of which 4 maybe non-ambulatory. Fire clearance was granted on August 23, 2022. LPA met with Digna Ramos (applicant-licensee).

LPA inspected the facility inside out. There is no body of water. LPA inspected the living room, dining area, kitchen, bedrooms, hallways, bathrooms, side and backyards. Bedrooms were observed appropriately furnished with adequate lighting and drawers. Facility has sufficient towels, extra bed sheets and comforters. Equipment and supplies for residents' personal hygiene are available and on site. Dinner and silver wares were observed sufficient for residents' use. Food supplies checked and observed good for seven days of non-perishables. Facility was observed equipped with refrigerator, microwave, dishwasher, washer and dryer. Cabinet for knives, cleaning supplies, and central storage for medications were observed with locks. Activity supplies were available. Outdoor activity space was observed furnished with tables, chairs and shade. The two-in-one carbon monoxide and smoke detector tested and observed functional. First aid kit checked and observed complete with manual.

Continued on LIC 809-C....
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE: DATE: 05/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/01/2023
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: GRAND OAK MANOR SUITE LLC
FACILITY NUMBER: 079201209
VISIT DATE: 05/01/2023
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...Continued from LIC 809

LPA observed the following:
1. Physical plant is not consistent with the facility sketch received by Central Application Bureau (CAB) and approved by the fire department. The sketch that was submitted did not include the second floor (three staff bedrooms, two staff bathrooms), the ADU unit, or the backyard.

2. Two fire extinguishers were present but did not have tags showing service dates.

3. There is damage to the roof at the back of the house.

4. The fireplace does not have a cover.

Upon receipt of proof of corrections for the items above, LPA Clancy-Czuleger will come to the facility again to verify. Once LPA has verified the corrections, LPA will inform CAB. Issuance of license is pending upon final review by CAB analyst.



Exit interview conducted and copy of this report provided
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023
LIC809 (FAS) - (06/04)
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