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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200579
Report Date: 09/23/2022
Date Signed: 09/23/2022 12:42:29 PM

Document Has Been Signed on 09/23/2022 12:42 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:P & P DEVELOPMENTAL SERVICESFACILITY NUMBER:
079200579
ADMINISTRATOR:TING, VICKY SFACILITY TYPE:
775
ADDRESS:4851-C LONE TREE WAYTELEPHONE:
(925) 813-1979
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY: 40CENSUS: 20DATE:
09/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Vicky Ting, AdministratorTIME COMPLETED:
12:50 PM
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On 09/23/22 at 11:30am, Licensing Program Analyst (LPA) Daisy Panlilio arrived unannounced to conduct infection control inspection. LPA met with administrator and explained the purpose of the visit. LPA observed 7 staff wearing face masks and 20 clients engaged in various activities at the facility.

LPA toured the facility including but not limited to front entrance, screening station, hand washing stations, bathroom, stimulation room, two (2) changing rooms, theater room, arts & crafts room, activity room, office/conference spaces and common areas. There is one central entry point for universal screening for staff, clients and visitors. A sign-in policy, visitor’s logs, no touch thermometer, additional face masks and hand sanitizer were observed at the screening station.

Cough/sneeze etiquette, social distancing signs were posted in common areas. The facility has two (2) bathrooms. Hot water temperature in a client's bathroom measured at 117 degrees, F. The facility temperature maintained at 75 degrees F. Facility maintains a 1:3 staff to client ratio. Drinking water is provided for clients in care. Clients supply own lunch and snacks.

Continued on next page, LIC 809-C

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2022
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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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: P & P DEVELOPMENTAL SERVICES
FACILITY NUMBER: 079200579
VISIT DATE: 09/23/2022
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Program provides training regarding independent living skills and social skills. Community outings, activities and exercise sessions are also provided. Toxins, medications and sharps observed stored locked. Staff does not handle client's cash resources. Facility has four vans to transport clients. Administrator is on site Monday through Friday (30 hours per week). First aid kit complete and smoke detectors were observed operational. Exits/passageways were observed free of obstruction.


There were no deficiencies observed/cited during inspection today.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 09/26/22:
LIC 309 Administrative Organization
LIC 308 Designation of Administrative Responsibility
LIC 500 Personnel Report
LIC 400 Affidavit Regarding Cash Resources
LIC 610D Emergency Disaster Plan including infection control plans.

Exit interview conducted and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022
LIC809 (FAS) - (06/04)
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