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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601547
Report Date: 12/07/2022
Date Signed: 12/07/2022 03:11:45 PM


Document Has Been Signed on 12/07/2022 03:11 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:COUNTRY PLACE ASSISTED LIVINGFACILITY NUMBER:
075601547
ADMINISTRATOR:RICHARDSON, JENNIFERFACILITY TYPE:
740
ADDRESS:1715 OLIVE LANETELEPHONE:
(925) 778-5000
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:49CENSUS: 33DATE:
12/07/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Angeline Green, Care Coordinator
Glenn Jones, Maintenance Director		TIME COMPLETED:
02:30 PM
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On 12/07/22 at 1:45PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced case management visit regarding an incident report faxed to CCL on 12/06/22. LPA explained the purpose of the visit with the Care Coordinator (CC).

CC stated resident (R1) was first admitted at the facility on 12/10/2012. CC stated R1 was verbal, ambulatory, independent and did not display any signs of pain or discomfort. Staff stated R1 passed away on 12/06/22 at approximately 7:20AM in her sleep. Staff called 911 to report the death. Police arrived 12/06/22 and conducted a welfare check. R1's body was released by the coroner's office the same day. Administrator requested for a copy of R1's death certificate and will submit it to CCLD once available.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2022
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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