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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200876
Report Date: 04/20/2023
Date Signed: 04/20/2023 02:58:40 PM

Document Has Been Signed on 04/20/2023 02:58 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:ADULT PACIFIC CARE INCFACILITY NUMBER:
079200876
ADMINISTRATOR:LOIDA GAVILANFACILITY TYPE:
735
ADDRESS:2024 ALVARADO DRTELEPHONE:
(925) 978-4425
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 6CENSUS: 4DATE:
04/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Claudia Meze, Direct Support ProfessionalTIME COMPLETED:
03:05 PM
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On 4/20/2023 at 12:40PM, Licensing Program Analysts (LPAs) L. Hall and L. Alexander conducted an unannounced annual 1-year required inspection. LPAs met with Claudia Meza. Direct Support Professional (DSP), and explained the purpose of the visit. Administrator Loida Gavilan, arrived at 12:53PM. LPA toured the facility with Administrator. The administrator currently holds a certificate (#6042357735) that expires on 10/24/2024. The facility’s fire clearance was approved for six (6) ambulatory clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of four (4) total bedrooms and two (2 ) bathrooms. All indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 71 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 105.5 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Hand washing poster, paper towel, and soap observed at all hand washing stations. The supply of extra hygiene was available for residents. PPE and paper goods are sufficient. There is a minimum of 7-day non-perishables and 2-day perishables foods.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 04/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/20/2023
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: ADULT PACIFIC CARE INC
FACILITY NUMBER: 079200876
VISIT DATE: 04/20/2023
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Continued from LIC809.

Smoke detectors/carbon monoxide were in operating condition during visit. Fire extinguisher last serviced on 3/1/2023 Emergency Disaster Plan was last posted on 02/24/2023. First aid kit was observed to be complete. Fire drill was last conducted on 3/30/2023.

Two (2) staff records were reviewed, and both staff have criminal record clearance, First Aid and CPR certification. All four (4) clients' records were reviewed. LPAs also reviewed P & I and a sample of medication

The following forms to be updated and submitted to CCLD by 04/27/2023:
  • LIC 500 Personnel Report
  • LIC 400 Affidavit Regarding Client/Resident Cash Resources
  • LIC 402 Surety Bond
  • Client's roster
  • LIC 308 Designation of facility's Responsibility
  • LIC 610D Emergency disaster plan
  • Liability insurance.


No deficiencies cited during inspection.

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

DATE: 04/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023
LIC809 (FAS) - (06/04)
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