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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200109
Report Date: 12/20/2023
Date Signed: 12/20/2023 03:05:09 PM

Document Has Been Signed on 12/20/2023 03:05 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 IIFACILITY NUMBER:
079200109
ADMINISTRATOR:CERILO WILLIAM BELENFACILITY TYPE:
735
ADDRESS:4744 PALOMINO COURTTELEPHONE:
(925) 755-2555
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY: 6CENSUS: 4DATE:
12/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Chris DeVera, AdministratorTIME COMPLETED:
04:30 PM
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On 12/20/23 at 2:30PM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct an annual required inspection. LPA met with administrator (ADM) and explained the purpose of the visit.

LPA toured the facility including but not limited to the front entrance, screening station, hand washing stations, kitchen, bathrooms, bedrooms and common areas. There is one central entry point for universal screening for staff, clients and visitors. A sign-in policy, visitor’s logs, no touch thermometer, additional face masks and hand sanitizer were observed at the screening station. Cough/sneeze etiquette, social distancing signs were posted in common areas. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Facility has a 30-day supply of PPEs maintained at a central location and easily accessible for staff. Comfortable temperature is maintained at 73 deg F. Facility has a mitigation plan in place and maintains records of routine screening for clients and staff. The infection control leader is the ADM. Fire extinguisher was observed fully charged and last inspected on 08/11/23. LPA reviewed 2 staff and 3 client files. LPA observed P&I monies matched record logs and kept separate from facility funds.

LPA obtained the following documents from ADM:
· LIC500- Personnel Report
· LIC308- Designation of Facility Responsibility
· LIC610D- Emergency/Disaster Plan including infection control plans
· Evidence of Surety Bond

No deficiencies were observed during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2023
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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