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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200544
Report Date: 01/04/2024
Date Signed: 01/04/2024 11:59:50 AM

Document Has Been Signed on 01/04/2024 11:59 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: 9DATE:
01/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Lisa Kimble, Program DirectorTIME COMPLETED:
12:05 PM
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On 1/4/2024 at 10:30am, Licensing Program Analysts (LPAs) L. Hall and T. Syess-Gibson arrived unannounced to conduct an Annual 1-year required inspection. LPA met with Lisa Kimble, Program Manager, and explained the reason for the visit. The facility's fire clearance was approved for 15 ambulatory clients.

LPAs inspected the facility with Program Director, which included but not limited to the bathroom, common areas, and the outside area of the facility. LPA observed the facility to be free of odor, clean and in good repair. Outdoor space is provided and is free of hazards. There is a comfortable room temperature of 75 degrees Fahrenheit for clients in care. Grab bars mats were observed in bathrooms and throughout the facility. Clients bring their own lunches and snacks to facility. The hot water temperature in the shared bathroom measured 116.8 degrees. All observed toilets and hand washing stations are maintained in a safe, sanitary, operating condition. There are no bodies of water or fire safety hazards observed. Carbon monoxide and smoke detectors found to be in working order. Toxins and sharp objects were locked and inaccessible to clients. Fire extinguisher last services 11/9/2023. Fire drill last conducted 9/27/2023. First aid kit was checked and is complete.

LPA reviewed three (3) staff files and all have current first aid & CPR certification. LPA reviewed five (5) clients and all were current and complete.

No deficiencies were cited during this inspection.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 01/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/04/2024
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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