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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200587
Report Date: 10/19/2023
Date Signed: 10/19/2023 04:34:24 PM

Document Has Been Signed on 10/19/2023 04:34 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:LINDA'S RESIDENTIAL CARE II LLCFACILITY NUMBER:
079200587
ADMINISTRATOR:PORTILLO, ERLINDAFACILITY TYPE:
735
ADDRESS:5220 FEATHER WAYTELEPHONE:
(925) 565-5106
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY: 6CENSUS: 6DATE:
10/19/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Erlinda Portillo, AdministratorTIME COMPLETED:
05:00 PM
NARRATIVE
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On 10/19/23, while at the facility for another reason, Licensing Program Analyst (LPA) conducted an unannounced case management visit and met with administrator (ADM). LPA explained the purpose of the visit with ADM.

LPA toured the facility and observed the following deficiencies:
  • Missing toilet seats & covers in the master and common hallway bathrooms
  • Broken window locks in the master bathroom toilet area

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 10/19/2023 04:34 PM - It Cannot Be Edited


Created By: Daisy Panlilio On 10/19/2023 at 03:00 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LINDA'S RESIDENTIAL CARE II LLC
FACILITY NUMBER: 079200587

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/19/2023
Section Cited
CCR
87303(e)(B)(6)

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Toilet, handwashing and bathing facilities shall be maintained in operating condition.
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Deficiency corrected during visit.
Administrator installed new toilet seats with covers in both clients' bathrooms on 10/19/23.
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This requirement was not met as evidenced by missing toilet seat & covers in clients' bathrooms which posed a potential health & safety risk to clients in care.
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Type B
10/31/2023
Section Cited
CCR87303(a)

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The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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By POC due date, Administrator agreed to complete repair to master toilet window and submit copy of repair receipt to CCL in compliance with Title 22 Section 87303 (a).
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This requirement was not met as evidenced by broken window lock inside clients' master toilet area which posed a potential health & safety risk to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bennett Fong
LICENSING EVALUATOR NAME:Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023


LIC809 (FAS) - (06/04)
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