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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201269
Report Date: 08/04/2023
Date Signed: 08/04/2023 12:56:46 PM

Document Has Been Signed on 08/04/2023 12:56 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:HOME SWEET ELSIEFACILITY NUMBER:
079201269
ADMINISTRATOR:SORIANO, CHRISTINEFACILITY TYPE:
740
ADDRESS:280 ELSIE DRTELEPHONE:
(510) 507-2679
CITY:DANVILLESTATE: CAZIP CODE:
94526
CAPACITY: 6CENSUS: 0DATE:
08/04/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Christine Soriano, LicenseeTIME COMPLETED:
01:05 PM
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On 8/4/2023 at 12:15pm, Licensing Program Analyst (LPA) L. Hall conducted an announced pre-licensing inspection with Licensee, Christine Soriano.. The facility has an approved fire safety clearance for six (6) non-ambulatory and a hospice wavier for six (6) residents

LPA inspected the facility inside and out including but not limited to the bedrooms, bathrooms, common living areas, kitchen, garage and back yard. The facility has a total of five (5) bedroom and three (3) bathrooms. There were no bodies of water present during inspection. There is sufficient lighting around the facility. Residents rooms are equipped with the proper furniture, bedding. Bathrooms showers/tubs were equipped with grab bars and non skid mats. Passageways and hallways are free of obstruction. Licensee stated hot water temperature is measured at 109 degrees Fahrenheit. Locked cabinets available to store medications, toxins and sharps. Required posters are posted on the wall. Fire extinguisher was last serviced on 4/22/2023. First Aid kit was complete. Carbon monoxide and smoke detectors present.

LPA received prior approval from Licensing Program Manager (LPM), Y. Flores-Lairos to waive Comp III.

No issues noted during inspection. LPAs observed that facility is ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAU. Additional requirements may still be required.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 08/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2023
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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