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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200120
Report Date: 04/26/2023
Date Signed: 04/26/2023 02:51:46 PM

Document Has Been Signed on 04/26/2023 02:51 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 IVFACILITY NUMBER:
079200120
ADMINISTRATOR:CERILO WILLIAM A BELENFACILITY TYPE:
735
ADDRESS:5415 CHEROKEE WAYTELEPHONE:
(925) 470-3888
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY: 6CENSUS: 4DATE:
04/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Cerilo Willaim Belen, AdministratorTIME COMPLETED:
03:15 PM
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On 04/26/23 at 1:50PM, Licensing Program Analyst (LPA) Daisy Panliliot arrived unannounced to conduct an Annual Required Inspection. LPA explained the purpose of the visit with administrator.

LPA inspected the facility including, but not limited to, living room, kitchen, dining area, bathrooms, bedrooms, laundry area and outside areas. Screening station was observed near the front entrance with visitors logs, no touch temperature probe, hand sanitizer and additional masks. There were no bodies of water present. The facility has six (6) bedrooms and three (3) bathrooms. Two bedrooms and one bathroom are designated for staff use only. 2 day perishable and 7 day non perishable food supplies available. Facility maintained at 70 degrees, F. Hot water temperature in a client's bathroom measured at 108 deg F. Fire extinguisher was observed fully charged and last inspected 08/19/22, first aid kit complete, flashlights, smoke/carbon monoxide detectors operational. Emergency Disaster Plan dated 01/05/2022 posted near the kitchen. required posters centrally posted. Exits and passageways were observed free of obstruction. Fire and Earthquake Disaster drills conducted monthly. The infection control leader is the administrator.

LPA reviewed client/staff files, P&I monies, medication and medication logs.

email address: profmadwisdom@yahoo.com

There were no deficiencies cited during inspection.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2023
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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