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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200250
Report Date: 04/14/2022
Date Signed: 04/14/2022 12:44:02 PM

Document Has Been Signed on 04/14/2022 12:44 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:RIDGELINE HOMEFACILITY NUMBER:
079200250
ADMINISTRATOR:ALEXIS A ANCHETAFACILITY TYPE:
735
ADDRESS:4646 RIDGELINE DRIVETELEPHONE:
(925) 303-2406
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY: 6CENSUS: 5DATE:
04/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Cherry Sevilla (Staff)TIME COMPLETED:
01:00 PM
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On 4/14/2022 at around 11:55. Licensing Program Analysts (LPAs) L. Fici & D. Panlilio, was greeted by Cherry Sevilla (Staff). The administrator (Lucky Thammalangsy) was not present at the time of the visit and he granted Cherry permission to act on his behalf to sign the reports. LPAs observed 4 staff members wearing face masks and 5 clients eating lunch in the living room during visit.

Facility has a mitigation plan in place dated February 6, 2021 to mitigate the spread of COVID-19. LPAs discussed the completed mitigation plan (LIC 808) with administrator as well as COVID-19 infection control practices. LPAs 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 are posted throughout the facility to promote hand washing, cough/sneeze etiquette and physical distancing. Facility documents daily temperatures and COVID-19 symptom checks for staff and residents. Pathways were observed to be free of obstruction and fire hazards.

Continue on lic809-C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/14/2022
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: RIDGELINE HOME
FACILITY NUMBER: 079200250
VISIT DATE: 04/14/2022
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A written Emergency/Disaster plan dated February 1, 2022 was observed posted in the kitchen area on a bulletin board. Centrally stored medications were locked in a file cabinet located in the kitchen. Sharp objects were locked in the staff closet locked in a toolbox. Toxic chemicals were locked in cabinets in the garage.

Infection control designated leader is the administrator. All staff and residents have been fully vaccinated since March 2021. There was at least 7 days of nonperishable and 2 days of perishable foods. Emergency food supplies were observed stored in the garage locked; staff only is provided with keys to access the garage. Facility room temperature was maintained at 69 degrees Fahrenheit. Resident's bedrooms and bathrooms have COVID-19 signages. Fire extinguisher was observed fully charged and dated March 1, 2022. 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 04/15/22:
· LIC500- Personnel Report
· LIC308- Designation of Facility Responsibility
· LIC610E- Emergency/Disaster Plan
· Evidence of Liability Insurance

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

DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022
LIC809 (FAS) - (06/04)
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