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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600471
Report Date: 11/14/2022
Date Signed: 11/14/2022 02:00:48 PM

Document Has Been Signed on 11/14/2022 02:00 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: 6DATE:
11/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Mary Stewart, AdministratorTIME COMPLETED:
02:35 PM
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On 11/14/22 at 10:50AM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct infection control inspection. LPA met with administrator and explained the purpose of the visit. LPA observed two staff wearing face masks and 4 clients watching TV. S1 stated the other 2 clients were attending their day programs during visit.

LPA toured the facility including but not limited to front entrance, kitchen, bedrooms, bathrooms, screening station and 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. COVID signages were observed in the hallway, kitchen and bathrooms. Facility has sufficient 2-day perishable and 7-day non-perishable food supply. Facility has a 30-day supply of PPEs maintained at a central location and easily accessible for staff. Comfortable temperature is maintained at 75 deg F. Facility has a mitigation plan in place and maintains records of routine screening for clients and staff. The infection control leader is the administrator.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 11/15/22:
· 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: 11/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2022
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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