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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600471
Report Date: 02/25/2022
Date Signed: 02/25/2022 12:30:10 PM

Document Has Been Signed on 02/25/2022 12:30 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:S&S TLCFACILITY NUMBER:
075600471
ADMINISTRATOR:SURNEY, R. STEWART M.FACILITY TYPE:
735
ADDRESS:2505 CROCKER WAYTELEPHONE:
(925) 753-5210
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY: 6CENSUS: 5DATE:
02/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Mary Surney, Administrator
Connie Betz, DSP		TIME COMPLETED:
12:45 PM
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On 02/25/22 at 11AM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an infection control annual inspection and explained the purpose of the visit with staff/administrator. LPA spoke to administrator on the phone who authorized staff (S1) to act on her behalf & sign the reports. LPA observed 2 staff wearing face masks during visit.

LPA observed 5 clients watching TV in the living room. One client was at the day program during visit. Facility has a mitigation plan in place dated 04/26/21 to mitigate the spread of COVID-19. LPA discussed the completed mitigation plan (LIC 808) with staff/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 hand washing, cough/sneeze etiquette and physical distancing. Facility documents daily temperatures and COVID-19 symptom checks for staff and clients. Pathways were observed to be free of obstruction and fire hazards.

Continued on next page LIC 809-C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/25/2022
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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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: S&S TLC
FACILITY NUMBER: 075600471
VISIT DATE: 02/25/2022
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Centrally stored medications were locked in a cabinet inside a closet. Sharp objects were locked in lockbox in the kitchen area. Toxic chemicals were locked inside the laundry room. Infection control designated leader is the administrator. There was at least 7 days of nonperishable and 2 days of perishable foods. Emergency food supplies were observed stored in the garage. Facility room temperature was maintained at 74 degrees Fahrenheit. 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 observed fully charged. Smoke and Carbon monoxide detectors were operational.

Adequate supplies of PPE were also observed stored in the garage. Facility follows daily cleaning, sanitation of frequently touched common surfaces using Clorox and Lysol disinfectants. Two designated visitation areas were observed at the facility to promote social distancing.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 02/28/22:
· LIC500- Personnel Report
· LIC308- Designation of Facility Responsibility
· LIC610D- 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: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2022
LIC809 (FAS) - (06/04)
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