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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601572
Report Date: 03/24/2022
Date Signed: 03/24/2022 04:46:18 PM


Document Has Been Signed on 03/24/2022 04:46 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:LAYLOR CARE HOME FOR THE ELDERLYFACILITY NUMBER:
075601572
ADMINISTRATOR:CLARKE, SHARONFACILITY TYPE:
740
ADDRESS:5168 JUDSONVILLE DRIVETELEPHONE:
(925) 775-4245
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY:6CENSUS: 9DATE:
03/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Sharon Clarke, AdministratorTIME COMPLETED:
05:15 PM
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On 03/24/22 at 4pm, Licensing Program Analyst (LPA) Daisy Panlilio arrived unannounced to conduct Infection Control Inspection. LPA met with administrator and explained the purpose of the visit. LPA observed one staff (ADM) wearing a face mask during visit. LPA also observed no residents were living at the facility.

One central entry point has been designated for universal entry screening with the station located near the front entrance 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. Pathways were observed to be free of obstruction and fire hazards.

A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Facility has a mitigation plan dated 04/05/2021 and maintains record of routine screening for residents and staff.

No deficiencies cited during visit. Exit interview conducted and a copy of the report provided to administrator via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2022
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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