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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601547
Report Date: 05/27/2021
Date Signed: 05/27/2021 02:50:20 PM

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:COUNTRY PLACE ASSISTED LIVINGFACILITY NUMBER:
075601547
ADMINISTRATOR:RICHARDSON, SHERRYFACILITY TYPE:
740
ADDRESS:1715 OLIVE LANETELEPHONE:
(925) 778-5000
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:49CENSUS: 43DATE:
05/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Sherry Richardson, AdministratorTIME COMPLETED:
02:50 PM
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On 05/27/21 at 2PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an infection control annual inspection and explained the purpose of the visit with administrator. LPA observed 5 staff wearing face masks during visit. LPA observed 8 residents relaxing in the living room area during the visit. Facility has a mitigation plan in place dated 01/29/21 to mitigate the spread of COVID-19. LPA discussed the completed mitigation plan (LIC 808) with administrator as well as COVID-19 infection control practices. LPA inspected the facility inside and outside.

LPA observed a COVID-19 screening station located near the front entrance where staff performs temperature checks and COVID-19 symptoms for residents, visitors and incoming staff prior to the start of their work shift. Facility documents daily temperatures and COVID-19 symptom checks for staff and residents. COVID-19 signs are posted throughout the facility to promote handwashing, cough/sneeze etiquette and physical distancing. Pathways were observed to be free of obstruction and fire hazards.

Infection control designated leader is the administrator. All staff and residents have been fully vaccinated since February 2021.There was at least 7 days of nonperishable and 2 days of perishable foods. Emergency food supplies were observed stored in the pantry/2nd storage area.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2021
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: COUNTRY PLACE ASSISTED LIVING
FACILITY NUMBER: 075601547
VISIT DATE: 05/27/2021
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Facility room temperature was maintained at 77 degrees Fahrenheit. LPA observed the hallway bathroom has COVID-19 signages for proper handwashing. A certified 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 fully charged. Smoke and Carbon monoxide detectors were operational.

Adequate supplies of PPE (30 days supply) were also observed stored in the outside storage shed. Facility follows daily cleaning, sanitation of frequently touched common surfaces using Clorox and Lysol disinfectants.

Updated copies of the following documents were obtained during the visit:
· LIC500- Personnel Report
· LIC308- Designation of Facility Responsibility
· LIC610E- 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.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2021
LIC809 (FAS) - (06/04)
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