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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201362
Report Date: 05/10/2024
Date Signed: 05/10/2024 03:25:31 PM

Document Has Been Signed on 05/10/2024 03:25 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:CAMELLIA GARDENS CARE VILLAFACILITY NUMBER:
079201362
ADMINISTRATOR/
DIRECTOR:		MANALANG-ENRIQUEZ, JOYFACILITY TYPE:
740
ADDRESS:2832 MI ELANA CIRCLETELEPHONE:
(925) 945-1237
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY: 6CENSUS: 5DATE:
05/10/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Applicant Joy Manalang-EnriquezTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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On 05/10/2024 at 12:45 PM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to conduct a change of ownership prelicensing visit. Upon entry into the facility, the LPA informed Applicant Joy Manalang-Enriquez of the purpose of the visit.

The LPA toured the inside and outside of the facility. The LPA inspected the kitchen, common areas, bedrooms, bathrooms, and storage areas of the facility. The facility was clean, appropriately furnished, and well lit. More than the 2 days of perishable and 7 days of nonperishable food supplies were available. No body of water was on the facility grounds. Medications are centrally stored. The LPA reviewed the staff, resident, and facility records stored at the facility. Bathrooms and showers were observed to be fully functioning and clean. Carbon monoxide and smoke detectors operational and the fire extinguishers were last replaced on 03/13/2024. First aid kit inspected and complete. Facility has adequate emergency lighting.

Facility passed pre-licensing inspection and completed Component III training with the Applicant. Final review of application and license to be granted by Central Applications Bureau analyst.

No citations issued during inspection.

Exit interview conducted and a copy of this report provided to the Applicant.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2024
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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