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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201353
Report Date: 06/05/2024
Date Signed: 06/12/2024 09:42:23 AM

Document Has Been Signed on 06/12/2024 09:42 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:YVONNE'S HOME CARE SERVICESFACILITY NUMBER:
079201353
ADMINISTRATOR/
DIRECTOR:		DANIELS, CAROLYNFACILITY TYPE:
740
ADDRESS:2856 SHANE DRIVETELEPHONE:
(510) 964-4600
CITY:RICHMONDSTATE: CAZIP CODE:
94806
CAPACITY: 6CENSUS: 6DATE:
06/05/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:20 AM
MET WITH:JAHI SPEARS, CAREGIVERTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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****THIS IS AN AMENDED REPORT****

On 6/05/2024 at 10:20am, Licensing Program Analyst (LPA) Carol Fowler conducted an unannounced pre-licensing inspection (facility is in operation and changing facility type). LPA met with Jahi Spears, Caregiver. The facility has an approved fire safety clearance for six (6) ambulatory residents. During inspection LPA observed one (1) client in a bedroom, one (1) client in the community and all other residents were in the common area.

LPA inspected the facility inside and out including but not limited to the bedrooms, bathrooms, common living areas, kitchen, back yard. The facility has a total of four (4) bedrooms and two (2) bathrooms, one bedroom and bathroom is occupied by staff. No bodies of water observed. There is sufficient lighting around the facility. Client’s rooms are equipped with the proper furniture, bedding, and lighting. Bathrooms shower/tub was equipped with a nonskid mat. Passageways and hallways are free of obstruction. Locked cabinets available to store medications, toxins and sharps. Hot water temperature is measured at 120 degrees Fahrenheit in shared clients' bathroom. Fire extinguisher was last serviced on 2/01/2024. There is a minimum of 7-day non-perishables and 2-day perishables foods. First Aid kit was complete. Carbon monoxide and smoke detectors present and in working condition. Fire drill last conducted 1/19/2024.

Continue on LIC 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 06/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/05/2024
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: YVONNE'S HOME CARE SERVICES
FACILITY NUMBER: 079201353
VISIT DATE: 06/05/2024
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continue from LIC 809

LPA 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 with Administrator and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2024
LIC809 (FAS) - (06/04)
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