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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 03:17:07 PM


Document Has Been Signed on 12/07/2022 03:17 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:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Angeline Green, Care CoordinatorTIME COMPLETED:
03:30 PM
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On 12/07/22 at 1:30PM, Licensing Program Analyst (LPA) D Panlilio conducted an infection control annual inspection and explained the purpose of the visit with Care Coordinator (CC). LPA observed 7 staff wearing face masks and 14 residents enjoying the nice weather outdoor patio area.

Facility has a mitigation plan in place 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. Routine symptom checks are done for universal screening with visitor's log, hand sanitizer, gloves, face masks and no touch temperature probe. COVID-19 signs are posted throughout the facility to promote handwashing, cough/sneeze etiquette and physical distancing. Facility documents daily temperatures and COVID-19 symptom checks for staff and residents. 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. Facility room temperature was maintained at 76 degrees Fahrenheit. Adequate supplies of PPE were also observed stored in the various locations (storage area, med room and office). Facility follows daily cleaning, sanitation of frequently touched common surfaces using Clorox and Lysol disinfectants.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 12/08/22:
· LIC500- Personnel Report
· LIC308- Designation of Facility Responsibility
· LIC610E- Emergency/Disaster Plan/Infection Control Plans
· 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: 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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