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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200968
Report Date: 07/05/2023
Date Signed: 07/05/2023 03:16:57 PM

Document Has Been Signed on 07/05/2023 03:16 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:CONNECTED LIVING ANTIOCHFACILITY NUMBER:
079200968
ADMINISTRATOR:TRAIL, EDDIEFACILITY TYPE:
735
ADDRESS:2350 GALLOWAY COURTTELEPHONE:
(925) 826-6830
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY: 6CENSUS: 6DATE:
07/05/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Kay Trail, AdministratorTIME COMPLETED:
03:30 PM
NARRATIVE
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On 07/05/23 at 2:10 PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced case management visit and met with administrator (ADM). LPA explained the purpose of the visit with ADM.

During visit, LPA observed part of the living room was converted into a bedroom. ADM stated they completed the modification on 06/15/23. LPA advised ADM they are in violation of their original fire clearance due to unauthorized conversion of part of the living room into a bedroom. ADM advised they are in the process of securing a building permit and all required documents to request for another fire inspection has been submitted to CCL last week. Civil penalty of $500 assessed on today's date.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D.

Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 07/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/05/2023
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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Document Has Been Signed on 07/05/2023 03:16 PM - It Cannot Be Edited


Created By: Daisy Panlilio On 07/05/2023 at 03:03 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: CONNECTED LIVING ANTIOCH
FACILITY NUMBER: 079200968

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/28/2023
Section Cited
CCR
80086(a)

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Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change...
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By POC due date, Administrator agreed to complete and submit to CCL copy of approved building permit and updated facility sketch.
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This requirement was not met as evidenced by unauthorized modification of living room into a bedroom which posed a potential health & safety risk to client in care.
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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:Bennett Fong
LICENSING EVALUATOR NAME:Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2023


LIC809 (FAS) - (06/04)
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