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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 071440014
Report Date: 12/04/2023
Date Signed: 12/04/2023 04:18:28 PM

Document Has Been Signed on 12/04/2023 04:18 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:CONCORD HOUSE - SATELLITE IFACILITY NUMBER:
071440014
ADMINISTRATOR:LEYBA, SIS. MARY ANNFACILITY TYPE:
735
ADDRESS:2057 BONIFACIO STREETTELEPHONE:
(925) 825-9757
CITY:CONCORDSTATE: CAZIP CODE:
94520
CAPACITY: 3CENSUS: 3DATE:
12/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Sister Mary Ann Leyba, AdministratorTIME COMPLETED:
04:25 PM
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On 12/04/2023 at 2:55 PM, Licensing Program Analyst (LPA) P. Watson arrived unannounced to conduct Required 1 Year Annual inspection. LPA met with Administrator, Sister Mary Ann Leyba and explained the purpose of the visit. The facility’s fire clearance was approved for 3 Ambulatory.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 3 total bedrooms which all 3 bedrooms are occupied by the clients. All outdoor and indoor passageways are kept free of obstruction. A comfortable temperature for clients is maintained at 68 degree Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured within range of 105-120 degree Fahrenheit. All toilets, hand washing stations, and bathing stations are safe, sanitary and in operating condition. There is a minimum of 7 day supply of non-perishables and 2 day perishables food supply. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 01/05/2023.

At 3:55 PM, LPA reviewed 3 of 3 client records and medications. At 3:35 PM, LPA reviewed 3 staff records and 3 of 3 have current first aid training and associated to the facility.


No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Paris Watson
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2023
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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