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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200553
Report Date: 09/28/2021
Date Signed: 09/28/2021 11:28:13 AM

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:SAKURA HOMESFACILITY NUMBER:
079200553
ADMINISTRATOR:LEWIS, CLYDE H JRFACILITY TYPE:
735
ADDRESS:4914 STONEWOOD WAYTELEPHONE:
(510) 755-9836
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY:3CENSUS: 0DATE:
09/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Clyde Lewis, AdministratorTIME COMPLETED:
11:40 AM
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On 09/28/21 at 10AM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced annual inspection and met with administrator (ADM). LPA explained the purpose of the visit with ADM.

LPA observed no clients present at the facility during visit. ADM stated that he has not admitted any clients at the facility since he got his license on 09/15/2017. ADM stated he is currently living at the home with his family until he is vendorized by Regional Center of the East Bay (RCEB) to receive disabled clients. ADM stated once he is vendorized by RCEB and he secures three clients at the home, he will move his family to reside at a different location and operate this facility with proper staffing and comply with COVID-19 infection control requirements. LPA observed no central screening station at the front entrance as well as no COVID-19 signages present at the facility. ADM showed LPA a completed infection control mitigation plan (LIC808) dated 04/22/21. LPA discussed COVID-19 mitigation infection control practices and requirements with ADM during visit. ADM is the designated infection control leader. There was at least 7 days of nonperishable and 2 days of perishable foods. Emergency food supplies were observed stored in the garage. Facility room temperature was maintained at 74 degrees Fahrenheit. ADM stated he will be on site to oversee proper business operation and compliance with COVID-19 infection control practices once he operates the facility with clients. Fire extinguisher was observed fully charged. Smoke and Carbon monoxide detectors were operational.

No deficiencies cited during this visit. Exit interview conducted and a copy of this report provided to ADM.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021
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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