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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200914
Report Date: 12/20/2022
Date Signed: 12/20/2022 06:54:33 PM

Document Has Been Signed on 12/20/2022 06:54 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: DATE:
12/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Breinssel Edwards, CaregiverTIME COMPLETED:
02:20 PM
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On 12/20/2022 at 1:30PM, Licensing Program Analysts (LPAs) L. Hall and L. Holmes arrived unannounced to conduct an Infection Control Inspection. LPs met with Breinssel Edwards, Caregiver. LPAs spoke with Administrator Alfredo Limjoco, and was given approval to sign documents.

Upon entry, LPA's temperature was not checked. LPA observed screening station and COVID-19 signs were posted. LPA toured facility including but not limited to common areas, bathrooms stations, bedrooms, kitchen, garage and back yard. All hand washing stations were equipped with soap and paper towel. Hand washing posters were posted at hand washing stations. Hot water temperature in the shared clients’ bathroom was measured at 133.2 degrees Fahrenheit. Fire extinguisher purchased on 05/17/2022. There is a minimum of 7-day non-perishables and 2-day perishables foods.

During record review, LPA observed visitors log. LPA observed facility has a copy of Infection Control Plan on file. LPAs observed food and paper supplies are sufficient.

No deficiencies cited during this visit.

Exit interview conducted. A copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2022
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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