079200993-9-16-2020-15-AS-LIBO-BTHUWP-20200916155703

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200993
Report Date: 09/16/2020
Date Signed: 09/16/2020 03:59:03 PM

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:	DESIRED PEACE HOME CARE 2		FACILITY NUMBER:	079200993
ADMINISTRATOR:	LAM, PAUL K.		FACILITY TYPE:	740
ADDRESS:	2024 SAGE SPARROW STREET		TELEPHONE:	(925) 303-7816
CITY:	BRENTWOOD	STATE: CA	ZIP CODE:	94513
CAPACITY:	6	CENSUS: 0	DATE:	09/16/2020
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	01:05 PM
MET WITH:	Paul Lam		TIME COMPLETED:	04:10 PM

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 09/16/2020 at 1:05PM, Licensing Program Analyst (LPA) Leslie Ibo and Associate Governmental Program Analyst (AGPA) Jeremy Fong made a scheduled visit to this facility for the purpose of completing a Pre-licensing inspection. LPAs met with Applicant Paul Lam. LPAs observed no residents were present during today’s visit. Due to the current COVID-19 State order to shelter-in-place, the visit was conducted via video phone. At 1:20PM, analysts toured the entire premises indoors and outdoors. The facility has 6 bedrooms, 3 bathrooms including staff bathroom, single story house per facility sketch. All 6 bedrooms are designated for residents. Analysts observed 1 fire extinguishers which was in the main entry area. Smoke detectors and carbon monoxide detectors were observed operational and hard wired per applicant. The facility received a fire clearance dated 8/14/2020 with an approval for a total capacity of 5 residents approved for non-ambulatory and 1 approved ambulatory room which is bedroom #6. LPAs observed a locked cabinet for centrally stored medications in kitchen area. Kitchen and dining room floors are clean and sanitary, food preparation area has an operating ventilation fan, there are no pesticides, poisons, or other toxins stored in any food storage or preparation area, cleaning supplies are kept separate from food supply. There are enough amounts of tableware, tables, dishes, and utensils. There are enough amounts of equipment for the storage, preparation of food. All equipment and dishes are clean and in good repair and there is at least 1 dining room convenient to the kitchen. Hot water temperature was tested at 112 degrees Fahrenheit for the kitchen and 110 degrees Fahrenheit bathroom. Refrigerator temperature was observed at 40 degrees Fahrenheit and freezer was observed at zero degrees Fahrenheit. Continue LIC809C...

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2020

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: DESIRED PEACE HOME CARE 2	FACILITY NUMBER: 079200993
	VISIT DATE: 09/16/2020

NARRATIVE

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Six Bedrooms were observed furnished with a bed, bedding, and nightstand, a chair, and a closet space. There were no bodies of water present at the facility. Outside pathways to security exit gate were unobstructed. There is confidential storage for personnel and resident records. There are games, activity supplies, and reading materials available. There is an outdoor area, that appears comfortable and furnished for residents to entertain friends and relatives. Analysts observed the first aid kit was complete with manual. All exit doors in the facility are equipped with auditory signals. LPAs verified there is an active telephone line in the facility, which is currently operating.

During today's visit, analysts reviewed LIC 610E Emergency disaster plan/Fire and Earthquake drill requirements with applicant. LPAs observed the facility had the necessary posters in place (Complaint poster, LTCO poster, Rights to Council, etc). COVID-19 posters were also displayed in the main entrance, common areas and the bathrooms.

Component III has been waived.
No issues noted during inspection. LPAs observed that facility is ready to be licensed. However, this report will be submitted to the Central Application Branch (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by the CAB in Sacramento CA. Additional requirements may still be required.

Exit interview conducted with Paul Lam and a copy of this report provided via email.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2020

LIC809 (FAS) - (06/04)

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