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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200544
Report Date: 10/04/2022
Date Signed: 10/04/2022 10:42:30 AM

Document Has Been Signed on 10/04/2022 10:42 AM - 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:SAINT ANNE VILLAGE INCFACILITY NUMBER:
079200544
ADMINISTRATOR:KIMBLE, LISAFACILITY TYPE:
775
ADDRESS:2800 CAMINO DIABLOTELEPHONE:
(925) 240-4757
CITY:BYRONSTATE: CAZIP CODE:
94514
CAPACITY: 15CENSUS: 15DATE:
10/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Lisa Kimble, Administrator TIME COMPLETED:
11:00 AM
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On 10/4/2022 at 9:10 AM, Licensing Program Analyst (LPA), L. Ibo arrived announced to conduct an infection control annual inspection. LPA met Administrator Lisa Kimble; LPA explained the purpose of the visit. Facility has census of 15.

LPA toured the program with Administrator, Lisa Kimble including but not limited to the bathroom, common area, and washing station. LPA observed the facility to be free of odor, clean and in good repair. Outdoor space is provided and is free of hazards. The program provides snacks for clients. Toilets and hand washing stations are maintained in a safe, sanitary, operating condition. There are no bodies of water or fire safety hazards observed during visit. Indoor and outdoor passageways were kept free of obstruction. Cleaning supplies were locked in a cabinet.

There was an enough supply of toiletry supplies & PPE supplies. There are locked cabinets available to store toxins and medications. The facility is equipped with fire extinguishers, smoke detectors, carbon monoxide detectors and a complete first aid kit.

LPA observed the following and technical assistance provided to Administrator:

1. LPA requested a copy of infection control plan to be submitted no later than 10/10/2022

2. Facility need another trash bin with lid at the bathroom. - completed

3. LPA discussed with Administrator about the importance of maintaining facility capacity.

No deficiency cited during the visit. Exit interview conducted with Administrator. Copy of this report provided

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2022
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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