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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600282
Report Date: 09/15/2022
Date Signed: 09/15/2022 03:10:29 PM

Document Has Been Signed on 09/15/2022 03:10 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:SKYLINE VISTA HOMEFACILITY NUMBER:
075600282
ADMINISTRATOR:EVANS, SEANFACILITY TYPE:
735
ADDRESS:1337 MOKELUMNE DR.TELEPHONE:
(925) 984-1900
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY: 6CENSUS: 6DATE:
09/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Sean Evans, Administrator
LaTanya Henderson, DSP		TIME COMPLETED:
03:30 PM
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On 9/14/22 at 2:30PM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct infection control inspection. LPA met with staff (DSP1) and administrator (ADM) who authorized DSP1 to act on his behalf and sign the reports. LPA explained the purpose of the visit with DSP1 and ADM. LPA observed 2 staff wearing face masks assisting 6 clients at the facility.

LPA toured the facility including but not limited to common areas, kitchen, bedroom, and shared bathrooms. to front entrance, screening station, hand washing stations, common areas. There is one central entry point for universal screening for staff, clients and visitors. A sign-in policy, visitor’s logs, no touch thermometer, additional face masks and hand sanitizer were observed at the screening station. Cough/sneeze etiquette, social distancing signs were posted in common areas. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Facility has a 30-day supply of PPE maintained at a central location and easily accessible for staff. Facility has a mitigation plan in place and maintains records of routine screening for clients and staff.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 09/16/22:
· LIC500- Personnel Report
· LIC308- Designation of Facility Responsibility
· LIC610E- Emergency/Disaster Plan including infection control plans
· Evidence of Surety bond

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2022
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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