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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200553
Report Date: 07/06/2023
Date Signed: 07/06/2023 01:29:21 PM

Document Has Been Signed on 07/06/2023 01:29 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: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:
07/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Clyde Lewis, AdministratorTIME COMPLETED:
01:40 PM
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On 07/06/23 at 12:30PM, 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 level 4I 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 Title 22 regulations. LPA observed no central screening station at the front entrance as well as no COVID-19 signages present at the facility. LPA conducted one staff (ADM) interview and one staff (ADM) file review.

ADM showed LPA a completed infection control mitigation plan (LIC808) dated 04/22/21. LPA discussed infection control practices, operational & food service requirements, emergency/disaster preparedness, personnel and clients records requirements, incidental health & medical requirements, clients and staff personal rights, staffing & training, physical plant and incident/reporting requirements with ADM during visit.

Continued on next page, LIC 9099-C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/06/2023
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: SAKURA HOMES
FACILITY NUMBER: 079200553
VISIT DATE: 07/06/2023
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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 adult residential facility regulations 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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023
LIC809 (FAS) - (06/04)
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