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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200914
Report Date: 12/23/2021
Date Signed: 12/23/2021 12:57:26 PM

Document Has Been Signed on 12/23/2021 12:57 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:HARBOUR PLACE LLCFACILITY NUMBER:
079200914
ADMINISTRATOR:LIMJOCO, ALFREDOFACILITY TYPE:
735
ADDRESS:3000 HARBOUR DRIVETELEPHONE:
(415) 239-8145
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 6CENSUS: 0DATE:
12/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Brenissel Edwards, Staff TIME COMPLETED:
01:10 PM
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On 12/23/2021 at 11:55 am Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to conduct infection control inspection LPA meet with Staff Brenissel Edwards and explained the purpose of the visit.

During the Infection Control Inspection, LPA toured facility including but not limited to front entrance, bedrooms, common areas, kitchen, and backyard. Facility has a sufficient one week non-perishable food supply. There is one central entry point for universal screening for staff, residents, and visitors. Hand washing posters were observed. Facility staff were observed to be wearing proper PPE. The facility has a mitigation plan. Cabinet for knives, cleaning supplies, and central storage for medications were observed with locks.

Technical Assistance observed:
Fire extinguisher needs tags
A supply of PPE should be kept at the facility.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE: DATE: 12/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/23/2021
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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