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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600400
Report Date: 08/20/2024
Date Signed: 08/23/2024 03:53:15 PM

Document Has Been Signed on 08/23/2024 03:53 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:DELL'S RESIDENTIAL HOMEFACILITY NUMBER:
075600400
ADMINISTRATOR/
DIRECTOR:		MITCHELL, TRACYFACILITY TYPE:
735
ADDRESS:4444 BELLE DRIVETELEPHONE:
(925) 978-0345
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 4CENSUS: 4DATE:
08/20/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Tracy Mitchell, LicenseeTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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On 8/20/24 at 2:00 PM Licensing Program Analyst (LPA) Greg Clark arrived at the facility to conduct an unannounced case management visit. LPA knocked on the front door and rang the doorbell several times. LPA could hear that there were people in he garage so LPA knocked on the garage door. Nobody answered.

At approximately 3:00 PM LPA a observed an individual leaving the facility. That individual was later identified as a staff member by the licensee.

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. An immediate Civil Penalty of $500 is being issued today.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2024
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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Document Has Been Signed on 08/23/2024 03:53 PM - It Cannot Be Edited


Created By: Gregory Clark On 08/23/2024 at 01:22 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: DELL'S RESIDENTIAL HOME
FACILITY NUMBER: 075600400

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/23/2024
Section Cited
HSC
1533

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Health and Safety Code Section 1533 provides in part:
...any duly authorized officer, employee, or agent of the State Department of Social Services may, upon presentation of proper...
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Licensee to instruct all staff to answer the door at all times and letter affirming that to CCL by POC dte
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Health and Safety Code Section 1533 provides in part:

...any duly authorized officer, employee, or agent of the State ...identification, enter and inspect any place providing personal care, supervision, and services at any time, with or without advance notice, to secure compliance with, or to prevent a violation of, any provision of this chapter.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Gregory Clark
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2024


LIC809 (FAS) - (06/04)
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