<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200927
Report Date: 11/16/2021
Date Signed: 11/16/2021 11:18:22 AM

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:SMG RESIDENTIAL CARE INCFACILITY NUMBER:
079200927
ADMINISTRATOR:GONZALEZ, MARIA IFACILITY TYPE:
740
ADDRESS:2833 FORTUNA COURTTELEPHONE:
(925) 209-0791
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:6CENSUS: 6DATE:
11/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Maria Gonzalez, AdministratorTIME COMPLETED:
11:30 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 11/16/21 at 10:00AM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an infection control annual inspection and met with administrator (ADM). LPA explained the purpose of the visit with ADM. During visit, LPA observed 5 residents at the facility, 3 watching TV and 2 resting inside their bedrooms with one staff wearing a face mask.

Facility has a mitigation plan in place dated 01/23/21 to mitigate the spread of COVID-19. LPA discussed the completed mitigation plan (LIC 808) with ADM as well as COVID-19 infection control practices. LPA inspected the facility inside and outside. Facility room temperature was maintained at 73 degrees Fahrenheit. Resident's bedrooms and bathrooms have COVID-19 signages. Fire extinguisher was observed fully charged. Smoke and Carbon monoxide detectors were operational.

One central entry point has been designated for universal entry screening with the station located near the front entrance with visitor's log, hand sanitizer, face masks and no touch temperature probe. COVID-19 signs were observed posted in the common hallway to promote handwashing, cough/sneeze etiquette and physical distancing.

Continued on next page LIC 809-C
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
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: SMG RESIDENTIAL CARE INC
FACILITY NUMBER: 079200927
VISIT DATE: 11/16/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Facility documents daily temperatures and COVID-19 symptom checks for staff and residents. Pathways were observed to be free of obstruction and fire hazards.

A written Emergency/Disaster plan dated 01/20/21 was posted near a Lan line phone in the kitchen. Centrally stored medications were locked in the kitchen cabinets. Sharp objects were locked inside the kitchen drawer. Toxic chemicals were locked in the garage. Infection control designated leader is the ADM. All staff and residents have been fully vaccinated with booster shots since 11/10/21.There was at least 7 days of nonperishable and 2 days of perishable foods. Emergency food supplies were observed stored in the garage.

Adequate supplies of PPE were also observed stored in the garage. Facility follows daily cleaning, sanitation of frequently touched common surfaces using Clorox and Lysol disinfectants. The facility has auditory signals on each exit door.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 11/14/2021:
· LIC500- Personnel Report
· LIC308- Designation of Facility Responsibility
· LIC610E- Emergency/Disaster Plan
· Evidence of Liability Insurance

No deficiencies cited during this visit. Exit interview conducted and a copy of this report provided to ADM.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2