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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200096
Report Date: 04/13/2022
Date Signed: 04/13/2022 01:40:02 PM

Document Has Been Signed on 04/13/2022 01:40 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:SMETZER HOMEFACILITY NUMBER:
079200096
ADMINISTRATOR:ALEX ANCHETAFACILITY TYPE:
735
ADDRESS:5461 SMETZER WAYTELEPHONE:
(510) 798-4660
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY: 6CENSUS: 6DATE:
04/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Lucky Thammalangsy, AdministratorTIME COMPLETED:
01:55 PM
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On 04/13/22 at 12PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an infection control annual inspection and explained the purpose of the visit with administrator. LPA observed 4 staff wearing face masks during visit assisting 6 clients. Facility has a mitigation plan in place dated 02/06/21 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.

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 were posted throughout the facility to promote handwashing, cough/sneeze etiquette and physical distancing. A written Emergency/Disaster plan dated 02/01/22 was posted in the kitchen bulletin board for staff, clients and visitors to read.

Centrally stored medications were locked in the dining room cabinets. Sharp objects were also locked in the dining room cabinet. Toxic chemicals were locked inside the garage. Infection control designated leader is the administrator.

Continued on next page LIC 809-C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 04/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2022
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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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: SMETZER HOME
FACILITY NUMBER: 079200096
VISIT DATE: 04/13/2022
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All staff and 5 clients have been fully vaccinated since November 1, 2021.
There was at least 7 days of nonperishable and 2 days of perishable foods. Emergency food supplies were observed stored in the pantry and garage.

Facility room temperature was maintained at 72 degrees Fahrenheit. Administrator is on site a minimum of 20 hours a week to oversee proper business operation. LPA observed fire extinguisher was fully charged. Smoke and Carbon monoxide detectors were operational. Adequate supplies of PPE were also observed stored in the garage. 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 04/14/22:
· LIC500- Personnel Report
· LIC308- Designation of Facility Responsibility
· LIC610D- Emergency/Disaster Plan
· Evidence of Liability Insurance & Surety Bond

No deficiencies cited during this visit. Exit interview conducted and a copy of this report provided via email.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2022
LIC809 (FAS) - (06/04)
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