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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201226
Report Date: 04/17/2023
Date Signed: 04/17/2023 10:14:35 AM

Document Has Been Signed on 04/17/2023 10:14 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:ST LOUIS CARE HOMEFACILITY NUMBER:
079201226
ADMINISTRATOR:COLLADO, CHARMAINEFACILITY TYPE:
740
ADDRESS:921 ST LOUIS CTTELEPHONE:
(925) 954-7777
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY: 6CENSUS: 0DATE:
04/17/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Charmaine Cruz, Applicant- AdministratorTIME COMPLETED:
10:18 AM
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Licensing Program Analyst (LPA) Jill Clancy-Czuleger, conducted an announced pre-licensing inspection. License application is for 6 total capacity, of which 2 maybe non-ambulatory. Fire clearance was granted on November 9, 2022. LPA met with Charmaine Cruz (applicant- administrator) and Joper Collado (Maintenance Manager).

LPA inspected the facility inside out. There is no body of water. Physical plant is consistent with the facility sketch received by Central Application Bureau (CAB) and approved by the fire department. 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.

Fire extinguishers were observed fully charge and tags showing that they were purchased on October 23, 2022. The two-in-one carbon monoxide and smoke detector tested and observed functional. First aid kit checked and observed complete with manual. Hot water temperature in one of the bathrooms tested and measured at 108.8 degrees Fahrenheit.

There are no corrections to be made. Exit interview was conducted, and a copy of this report has been given.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE: DATE: 04/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/17/2023
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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