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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200146
Report Date: 02/14/2024
Date Signed: 02/14/2024 03:14:53 PM

Document Has Been Signed on 02/14/2024 03:14 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:COLOSSEUM HOMEFACILITY NUMBER:
079200146
ADMINISTRATOR:ALEX ANCHETAFACILITY TYPE:
735
ADDRESS:1995 COLOSSEUM WAYTELEPHONE:
(925) 756-7230
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY: 6CENSUS: 5DATE:
02/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Lucky Thammalangsy, Administrator
Winnie Ufert, DSP		TIME COMPLETED:
05:30 PM
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On 02/14/24 at 2PM, Licensing Program Analyst (LPA) D Panlilio arrived to conduct an unannounced required annual inspection. LPA explained the purpose of the visit with administrator (ADM). LPA observed 3 clients at the facility while the other 2 clients were attending their day programs.

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. COVID-19 posters were displayed in kitchen area bulletin board. 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 70 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 administrator. Fire extinguisher was observed fully charged and last inspected on 02/06/24. Smoke and Carbon monoxide detectors were operational. LPA reviewed 4 staff and 5 client files. LPA also conducted 2 staff and 2 client interviews during visit.

Continued on 809-C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2024
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: COLOSSEUM HOME
FACILITY NUMBER: 079200146
VISIT DATE: 02/14/2024
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Updated copies of the following documents were obtained from administrator:
· LIC500- Personnel Report
· LIC308- Designation of Facility Responsibility
· LIC610D- Emergency/Disaster Plan including infection control plans
· Evidence of Surety Bond

No deficiencies cited 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: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024
LIC809 (FAS) - (06/04)
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