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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 071440106
Report Date: 06/11/2021
Date Signed: 06/11/2021 06:03:04 PM

Document Has Been Signed on 06/11/2021 06:03 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:CONCORD HOUSEFACILITY NUMBER:
071440106
ADMINISTRATOR:LEYBA, MARY ANNFACILITY TYPE:
735
ADDRESS:2301 MT. DIABLO ST.TELEPHONE:
(925) 825-4423
CITY:CONCORDSTATE: CAZIP CODE:
94520
CAPACITY: 16CENSUS: 12DATE:
06/11/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
05:15 PM
MET WITH:Mary Ann Leyba, AdministratorTIME COMPLETED:
06:30 PM
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On 06/11/21 at 5:15PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an infection control annual inspection and explained the purpose of the visit with administrator. LPA observed 2 staff wearing face masks during visit. LPA observed 12 clients eating dinner during visit. Facility has a mitigation plan in place dated 03/04/21 to mitigate the spread of COVID-19. LPA discussed the completed mitigation plan (LIC 808) with administrator as well as COVID-19 infection control practices. LPA inspected the facility inside and outside.

One central entry point has been designated for universal entry screening with the station located near the front entrance with visitor's log, hand sanitizer, gloves, face masks and no touch temperature probe. COVID-19 signs are posted throughout the facility to promote handwashing, cough/sneeze etiquette and physical distancing. Facility documents daily temperatures and COVID-19 symptom checks for staff and residents. Pathways were observed to be free of obstruction and fire hazards.

A written Emergency/Disaster plan dated 07/16/20 was posted in a common area near the main entrance. Centrally stored medications were locked in office drawers. Sharp objects were locked in the office cabinets. Toxic chemicals were locked in the hallway closet.

Continued on next page LIC 809-C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 06/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/11/2021
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: CONCORD HOUSE
FACILITY NUMBER: 071440106
VISIT DATE: 06/11/2021
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Infection control designated leader is the administrator. All staff and clients have been fully vaccinated since February 26, 2021. There was at least 7 days of nonperishable and 2 days of perishable foods. Emergency food supplies were observed stored in the pantry. Facility room temperature was maintained at 72 degrees Fahrenheit. Resident's bedrooms and bathrooms have COVID-19 signages. A certified administrator is on site a minimum of 20 hours a week to oversee proper business operation and compliance with COVID-19 infection control practices. Fire extinguisher was fully charged and last inspected on 01/21/2021. Smoke and Carbon monoxide detectors were operational.

Adequate supplies of PPE were also observed stored in the basement. Facility follows daily cleaning, sanitation of frequently touched common surfaces using Clorox and Lysol disinfectants. The facility has auditory signals on each resident's exit doors.

Updated copies of the following documents were given by administrator for facility file:
· LIC500- Personnel Report
· LIC308- Designation of Facility Responsibility
· LIC610E- Emergency/Disaster Plan
· Evidence of Liability Insurance

No deficiencies cited during this visit. Exit interview conducted and a copy of this report provided to administrator.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021
LIC809 (FAS) - (06/04)
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