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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200055
Report Date: 04/06/2023
Date Signed: 04/06/2023 12:54:24 PM

Document Has Been Signed on 04/06/2023 12:54 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:SUMMERFIELD HOMES #1FACILITY NUMBER:
079200055
ADMINISTRATOR:MARGARITA D PAGDANGANANFACILITY TYPE:
735
ADDRESS:5313 SUMMERFIELD DRIVETELEPHONE:
(925) 706-9990
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY: 6CENSUS: 6DATE:
04/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Margarita Pagdanganan, AdministratorTIME COMPLETED:
12:30 PM
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On 04/06/23 at 10AM, Licensing Program Analysts (LPAs) D Panlilio and L Holmes conducted an unannounced annual inspection and met with administrator (ADM). LPAs explained the purpose of the visit with ADM. LPAs observed no clients at the facility during visit. ADM stated they were all attending their individual day programs. ADM stated this is a level 3 facility with the Regional Center of the East Bay (RCEB).

LPA toured the facility inside out with ADM. LPA inspected the living room, kitchen, dining area, bedrooms, bathroom, laundry room, side, and backyards. Food supplies were observed sufficient good for seven (7) days of non-perishables and two (2) days of perishables, and protected from contamination. Facility has working carbon monoxide and smoke alarm detectors. Fire extinguisher checked, observed fully charged, and tag showed serviced on 08/04/2022. Hot water temperature in the bathroom was tested and measured at 105.1 degrees Fahrenheit. First aid kit inspected and observed complete with manual. Facility staff conducts fire and earthquake drills with clients every other month.

All indoor and outdoor passageways were free of obstructions. Disinfectants and cleaning solutions were locked and inaccessible to clients. All bedrooms were equipped with night lights, chair, sufficient drawers, and beds with clean covers, mattress pads, and pillows. The toilet and bathing areas were observed safe and in operating condition. Cabinet in the kitchen where medications are centrally stored were observed locked.

Staff and clients' files were reviewed. Clients' cash resources records were checked. Medications and Centrally Stored Medication Records were inspected.

Continued on next page, LIC 809-C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/06/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: SUMMERFIELD HOMES #1
FACILITY NUMBER: 079200055
VISIT DATE: 04/06/2023
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LPAs collected the following documents from ADM during visit:
1. LIC308 Designation of Facility Responsibility.
2. LIC500 Personnel Report.
3. LIC610D Emergency Disaster Plan.
4. Copy of proof of Surety Bond Coverage.
5. Copy of administrator certificate (certificate # 6038864735; expiration date: 03/09/2024)

No deficiencies cited during this visit.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023
LIC809 (FAS) - (06/04)
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