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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 071440106
Report Date: 06/20/2024
Date Signed: 06/20/2024 03:33:08 PM

Document Has Been Signed on 06/20/2024 03:33 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:CONCORD HOUSEFACILITY NUMBER:
071440106
ADMINISTRATOR/
DIRECTOR:		LEYBA, MARY ANNFACILITY TYPE:
735
ADDRESS:2301 MT. DIABLO ST.TELEPHONE:
(925) 825-4423
CITY:CONCORDSTATE: CAZIP CODE:
94520
CAPACITY: 16CENSUS: 13DATE:
06/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:Mary Ann Leyba, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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On 06/20/2024 at 1:20PM, Licensing Program Analyst (LPA) T.Syess-Gibson conducted an unannounced annual 1-year required inspection. LPA met with Mary Ann Leyba, Administrator and explained the purpose of the visit. The administrator currently holds a certificate (#6021638735) that expires on 12/18/2024. The facility’s fire clearance was approved for sixteen (16) ambulatory clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, garage, and back yard. The facility consists of Sixteen(16) total bedrooms and Seven (7) bathrooms. One (1) bedroom used by staff. All indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 72 degrees 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 at 106.2 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Paper towel, and soap observed at all hand washing stations. The supply of extra hygiene was available for residents. There is a minimum of 7-day non-perishables and 2-day perishables foods.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 01/05/2024. Emergency Disaster Plan was last posted on 08/03/2023. First aid kit was observed to be complete.

Continued LIC809C

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2024
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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: CONCORD HOUSE
FACILITY NUMBER: 071440106
VISIT DATE: 06/20/2024
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Continued from LIC809.

LPA reviewed five (5) resident records and three (3) staff records, and they were current and complete.

LPA requested the following documents to be submitted to CCLD by 06/27/2024:

· LIC 308 Designation of Administrative Responsibility
· LIC 309 Administrative Organization
· LIC 500 Personnel Report
· LIC 610D Emergency Disaster Plan
· Liability Insurance

No deficiencies observed during visit.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
LIC809 (FAS) - (06/04)
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