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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200828
Report Date: 06/03/2022
Date Signed: 06/03/2022 03:00:26 PM

Document Has Been Signed on 06/03/2022 03:00 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:SWEET RIVER RESIDENTIAL CAREFACILITY NUMBER:
079200828
ADMINISTRATOR:MENJIVAR, KAYLAFACILITY TYPE:
735
ADDRESS:319 ROSS AVETELEPHONE:
(925) 250-3994
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 4CENSUS: 4DATE:
06/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Kayla Menjivar, AdministratorTIME COMPLETED:
03:05 PM
NARRATIVE
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On 6/3/2022 at 1:50PM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Infection Control Inspection. LPA met with Kayla Menjivar, Administrator, and explained the purpose of the visit.

Upon entry, LPA's temperature was checked. LPA observed screening station that contained hand sanitizer and sign-in book. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, kitchen, and backyard. LPA observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap, paper towel, and hand washing poster. Hot water temperature in the shared clients’ bathroom was measured at 101.3 degrees Fahrenheit. Fire extinguisher was last serviced on 10/12/2021.

During record review, LPA observed facility has a copy of Mitigation Plan on file. LPA observed PPE, food and paper supplies are sufficient.

The following forms are to be updated and submitted to CCLD by 6/10/2022:

-LIC500 Personnel Report
-LIC308 Designation of Administrative Responsibility

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 06/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/03/2022
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: SWEET RIVER RESIDENTIAL CARE
FACILITY NUMBER: 079200828
VISIT DATE: 06/03/2022
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Continued from LIC809.

-LIC610D Emergency Disaster Plan

The following deficiency were observed:

-At 1:55PM, LPA observed Staff 3 (S3) was not associated to the facility.

The following deficiency was observed (see LIC809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/03/2022 03:00 PM - It Cannot Be Edited


Created By: Laura Hall On 06/03/2022 at 02:24 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: SWEET RIVER RESIDENTIAL CARE
FACILITY NUMBER: 079200828

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(1)
80019 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:
(1) Obtain a California clearance or a criminal record exemption as required by the Department or
This requirement is not met as evidenced by:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review), the licensee did not comply with the section cited above in having S2 associated to facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/04/2022
Plan of Correction
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Administrator will submit LIC9182 and a copy of S2's identification to associate S2 to CCLD by POC date. Administrator submitted LIC9182 and a copy of S2's identification to LPA during inspection and added S2 via guardian. Deficiency cleared.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 06/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2022


LIC809 (FAS) - (06/04)
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