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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200158
Report Date: 03/17/2023
Date Signed: 03/17/2023 02:34:16 PM

Document Has Been Signed on 03/17/2023 02:34 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:REBEKAH'S PLACE IIFACILITY NUMBER:
079200158
ADMINISTRATOR:NANCY BELLAFACILITY TYPE:
735
ADDRESS:5193 BROOKSIDE LANETELEPHONE:
(925) 969-0151
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY: 6CENSUS: 6DATE:
03/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Rebecca Hernandez, Administrator/LicenseeTIME COMPLETED:
02:45 PM
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On 3/17/2023 at 11:55 AM, Licensing Program Analyst (LPA) P. Watson arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Rebecca Hernandez and explained the purpose of the visit. The facility’s fire clearance was approved for 6 Ambulatory.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 4 total bedrooms which 3 bedrooms are occupied by the clients and 1 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 70 degree Fahrenheit (F). LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured within the range of 105 degrees F and 120 degrees F. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. The supply of extra hygiene’s were available for clients. There is a minimum of 7 day supply of non-perishable and 2 day perishables food supply.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 05/13/2022. Emergency Disaster Drill was last posted on 10/22/2022. First aid kit was observed to be complete. Fire drill was last conducted on 10/22/2022.


Report continues on 809C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Paris Watson
LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2023
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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: REBEKAH'S PLACE II
FACILITY NUMBER: 079200158
VISIT DATE: 03/17/2023
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At 12:30 PM, 6 of clients’ records were reviewed. At 12:10 PM, 5 staff records were reviewed, and 5 of 5 have current first aid training and associated to the facility. A sample of 3 client’s medications were reviewed.


Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 03/31/2023 :

LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 402 Surety Bond
LIC 610D Emergency Disaster Plan


No deficiencies were cited during this inspection. Exit interview conducted and a copy of this report will be provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Paris Watson
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2023
LIC809 (FAS) - (06/04)
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