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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200814
Report Date: 09/12/2024
Date Signed: 09/12/2024 01:00:29 PM

Document Has Been Signed on 09/12/2024 01:00 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:SFBAY CARE - ANTIOCHFACILITY NUMBER:
079200814
ADMINISTRATOR/
DIRECTOR:		LIMJOCO, FREDDIEFACILITY TYPE:
735
ADDRESS:4956 SPUR WAYTELEPHONE:
(415) 405-6503
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY: 6CENSUS: 4DATE:
09/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Freddie Limjoco, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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On 09/12/24 at 11:30 AM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct an annual requiredl inspection. LPA met with administrator (ADM) and staff (S1, S2, S3) and explained the purpose of the visit.

At 11:45 AM, LPA toured the facility including but not limited to common areas, kitchen, bedroom, and shared bathrooms. to front entrance, screening station, hand washing stations, 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. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Facility has a 30-day supply of PPEs maintained at a central location and easily accessible for staff. Comfortable temperature is maintained at 74 deg F. Facility has a mitigation plan in place and maintains records of routine screening for residents and staff. The infection control leader is the administrator. Hot water temperature was measured at 118 deg F. LPA reviewed 4 staff and 4 client files during visit.

Updated copies of the following documents were obtained from administrator:
· LIC500- Personnel Report
· LIC308- Designation of Facility Responsibility
· LIC610E- Emergency/Disaster Plan including infection control plans
· Evidence of Surety Bond

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: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2024
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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