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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200553
Report Date: 08/23/2024
Date Signed: 08/23/2024 01:58:05 PM

Document Has Been Signed on 08/23/2024 01:58 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/
DIRECTOR:		LEWIS, CLYDE H JRFACILITY TYPE:
735
ADDRESS:4914 STONEWOOD WAYTELEPHONE:
(510) 755-9836
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY: 3CENSUS: 0DATE:
08/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:25 PM
MET WITH:Clyde Lewis, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On 08/23/24 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 ADM has a current administrator certificate# 6024017735 which expires 04/10/2025.

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 fire extinguisher fully charged and purchased on 06/21/24.

LPA observed no central screening station at the front entrance as well as no COVID-19 signages present at the facility. 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.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2024
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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