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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201320
Report Date: 08/28/2024
Date Signed: 08/28/2024 01:56:22 PM

Document Has Been Signed on 08/28/2024 01:56 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:LA ORINDA CARE HOMEFACILITY NUMBER:
079201320
ADMINISTRATOR/
DIRECTOR:		JAIN, ASHAFACILITY TYPE:
740
ADDRESS:2180 LA ORINDA PLTELEPHONE:
(510) 449-5939
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY: 6CENSUS: 4DATE:
08/28/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:55 AM
MET WITH:PURITA SOLIMAN, CARESTAFFTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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On 8/28/2024 at 9:55am, Licensing Program Analyst (LPA) Carol Fowler conducted an un-announced pre-licensing visit. LPA met with Purita Soliman, Caregiver, and explained the purpose of the visit. The Licensee arrived at 12:00pm The facility has an approved fire safety clearance for five (5) non-ambulatory and one (1) bedridden residents.

LPA inspected the facility inside and out including but not limited to the bedrooms, bathrooms, common living areas, kitchen, garage, back yard. The facility has a six (6) bedrooms one (1) occupied by staff and two (2) bathrooms. No bodies of water observed. There is sufficient lighting around the facility. Clients rooms are equipped with the proper furniture, bedding, and lighting. Bathrooms showers/tubs were equipped with non skid mats. Locked cabinets available to store medications, toxins and sharps. Hot water temperature is measured at 124.9 degrees Fahrenheit in shared clients' bathroom. Carbon monoxide and smoke detectors present and operable. Facility inspection matches the sketch that was provided.

Facility needs to correct the following by 9/12/2024:

ยท repair fence and gate on the side yard.


Continued on LIC809C.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2024
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: LA ORINDA CARE HOME
FACILITY NUMBER: 079201320
VISIT DATE: 08/28/2024
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continue from LIC 809


Issues were noted during inspection. LPA observed that facility is not ready to be licensed. This report will be submitted to the Central Applications Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required.

Exit interview conducted with Licensee and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024
LIC809 (FAS) - (06/04)
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