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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601547
Report Date: 09/21/2021
Date Signed: 09/21/2021 12:02:14 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: 41DATE:
09/21/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Angeleen Green, Manager on DutyTIME COMPLETED:
12:15 PM
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On 09/21/21 at 11:30AM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced case management visit and met with manager on duty (MOD). LPA spoke with administrator (ADM) on the phone who authorized MOD to act on her behalf and sign the report. LPA explained the purpose of the visit to ADM and MOD.

ADM stated that the administrator for this facility is S1, who is temporarily on maternity leave. LPA discussed with ADM that she cannot be the administrator for 2 residential care facilities for the elderly (RCFE) located in two different regions. ADM understood and stated she will comply with this requirement.ADM will email a copy of facility's current Personnel Record (LIC 500) to LPA today, September 21, 2021.

Exit interview conducted and a copy of this report provided to MOD.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021
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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