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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601547
Report Date: 06/14/2023
Date Signed: 06/14/2023 02:10:23 PM


Document Has Been Signed on 06/14/2023 02:10 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: 38DATE:
06/14/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:58 PM
MET WITH:Shani Edwards, AdministratorTIME COMPLETED:
02:15 PM
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On 06/14/23 at 2PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced health and safety check case management visit. LPA explained the purpose of the visit with administrator (ADM).

During the health and safety check, ADM confirmed with LPA that resident (R1) is adjusting well in the community since admittance on 06/06/23. ADM stated R1 started playing domino's and cards with two other residents in the activities room. LPA observed R1 comfortably resting inside his bedroom and that there is no imminent health or safety concerns on today's date.

No deficiencies cited during the health and safety check. 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: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2023
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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