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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200330
Report Date: 12/26/2024
Date Signed: 12/26/2024 02:05:12 PM

Document Has Been Signed on 12/26/2024 02:05 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:BUENAVISTA HOME AT DAWNVIEWFACILITY NUMBER:
079200330
ADMINISTRATOR/
DIRECTOR:
ROBERTO S. PEREZFACILITY TYPE:
735
ADDRESS:5514 DAWNVIEW CT.TELEPHONE:
(925) 917-9640
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
12/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Roberto Perez, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:20 PM
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On 12/26/24 at 1PM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct a required annual inspection, met administrator (ADM) and explained purpose of the visit. ADM has a current administrator certificate # 7004540735 which expires 05/02/26.

At 1:20PM, LPA toured the facility including but not limited to the front entrance, screening station, kitchen, bathrooms, bedrooms and common areas. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, visitor’s logs, no touch thermometer, additional face masks and hand sanitizer were observed at the screening station. Emergency Disaster Plan, Complaint poster, Personal rights, Cough/sneeze etiquette, proper hand-washing signs were observed 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, paper, medications locked in cabinets. Comfortable temperature is maintained at 70 deg F. Hot water temperature was measured at 111.6 deg F. Facility has a mitigation plan in place and the infection control leader is the administrator. Inside and outside pathways were free of obstruction and fire hazards. Smoke and Carbon monoxide detectors were operational. Fire extinguisher was observed fully charged and last inspected on 08/14/24. LPA reviewed 3 staff and 5 client files.

Updated copies of the following documents were collected for facility file:
 LIC500- Personnel Report
 Client Roster
 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
Bennett FongTELEPHONE: (510) 622-2621
Daisy PanlilioTELEPHONE: (510) 286-4201
DATE: 12/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/26/2024
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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