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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201460
Report Date: 12/30/2024
Date Signed: 12/30/2024 01:17:22 PM

Document Has Been Signed on 12/30/2024 01:17 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:BUTTERCUP CARE HOMEFACILITY NUMBER:
079201460
ADMINISTRATOR/
DIRECTOR:		SCHAEFER, IRAIS A.FACILITY TYPE:
740
ADDRESS:993 OAK GROVE ROADTELEPHONE:
(562) 673-0803
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY: 6CENSUS: 3DATE:
12/30/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Irais Schaefer, Administrator TIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Jill Clancy-Czuleger, conducted an unannounced pre-licensing inspection. License application is for (6) total capacity, of which all maybe non-ambulatory and 1 maybe bedridden. Fire clearance was granted on November 15,2024. LPA met with Irais Schaefer (applicant-administrator).

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. LPAs 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 showed serviced May 03, 2024. The two-in-one carbon monoxide and smoke detector tested and observed functional. First aid kit checked and observed complete with manual.

LPAs observed the following:
Hot water temperature in one of the bathrooms tested and measured at 130.0 degrees Fahrenheit.

Upon receipt of the proof of corrections for the item above, LPA Clancy-Czuleger will inform CAB. Issuance of license is pending upon final review by CAB analyst.

Exit interview conducted and copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE: DATE: 12/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/30/2024
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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