079201008-10-19-2020-15-AS-DPAO-BUJR22-20201019123736

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079201008
Report Date: 10/19/2020
Date Signed: 10/19/2020 12:39:46 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:	TEMESCAL RESIDENTIAL CARE HOME CORP.		FACILITY NUMBER:	079201008
ADMINISTRATOR:	MELANIO, ANDRES JR JAGARAP		FACILITY TYPE:	740
ADDRESS:	4580 TEMESCAL COURT		TELEPHONE:	(925) 813-5700
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94531
CAPACITY:	6	CENSUS: 3	DATE:	10/19/2020
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Andres Melanio Jr, Administrator/Applicant		TIME COMPLETED:	10:45 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 10/19/20 at 09:30 AM, Licensing Program Analyst (LPA) D. Panlilio conducted a tele-visit pre- licensing inspection and met with Administrator/Applicant Andres Melanio Jr. LPA explained to applicant that this visit is being conducted via Face-time in compliance with the shelter in place order of the governor. This pre-licensing is a change of ownership from old facility Alcaysa Residential Care Home # 079200737. The Administrator/Applicant was not physically available to sign this report due to the COVID-19 shelter in place order. During the tele-visit, LPA observed 3 residents resting inside each of their bedrooms with 3 staff assisting them during the tele-visit. Fire clearance was approved for 6 non-ambulatory residents of which 1 may be bedridden. LPA along with Administrator/Applicant, toured the facility via Face-time tele-visit inside and outside including but not limited to resident's bedrooms, bathrooms, dining room, common living areas, kitchen, and outside patios. LPA observed sufficient lighting around the facility. Resident's rooms were equipped with the proper furniture and lighting. Resident's rooms had proper bedding and linens. Bathrooms were equipped with grab bars, nonskid mats, and hygiene items. No bodies of water were present at the facility. Living room is equipped with the proper furniture for the residents. All toxins and sharp objects were observed locked. Passageways and hallways were free of obstruction. Two fire extinguishers were observed last inspected on 04/06/20. Smoke detectors and Carbon Monoxide detectors were tested operational. Medication cabinet was locked and first aid kit was complete. All exit doors in the facility are equipped auditory signals. Hot water temperature was measured at 110.5 degrees Fahrenheit. Continued on next page, LIC 809-C

SUPERVISOR'S NAME: Rajind Basi	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2020

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: TEMESCAL RESIDENTIAL CARE HOME CORP.	FACILITY NUMBER: 079201008
	VISIT DATE: 10/19/2020

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LPA observed 7 day perishable / 2 weeks nonperishable food supplies in the kitchen and emergency food supplies in the garage. LPA observed the facility had the necessary COVID-19, Ombudsman and CCLD required posters in place. LPA also observed an updated Emergency/Disaster Plan (LIC 610E) completed.

Facility has passed the pre-licensing inspection and no deficiencies were observed.
Facility is ready to be licensed. This report will be submitted to the Central Application Unit (CAU) and a final review of the application will be conducted for final approval. Additional requirements may still be required.

Exit interview conducted and a copy of this report provided via email to Administrator.

SUPERVISOR'S NAME: Rajind Basi	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2020

LIC809 (FAS) - (06/04)

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