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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201011
Report Date: 01/10/2025
Date Signed: 01/10/2025 01:15:08 PM

Document Has Been Signed on 01/10/2025 01:15 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:THOMAS HOMEFACILITY NUMBER:
079201011
ADMINISTRATOR/
DIRECTOR:		JEFFREY MEIMBANFACILITY TYPE:
735
ADDRESS:1000 THOMAS CTTELEPHONE:
(925) 238-8459
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 4CENSUS: 4DATE:
01/10/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Essel Meimban, Direct Support ProfessionalTIME VISIT/
INSPECTION COMPLETED:
01:25 PM
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On 1/10/2025 at 10:20pm, Licensing Program Analyst (LPA) L. Hall conducted an unannounced 1-year required inspection. LPA met with Essel Meimban, Direct Support Professional. Administrator Jeffrey Meimban, arrived at 12:30pm, and LPA explained the purpose of the visit Administrator certificate #702713375 expires 8/30/2025. The facility’s fire clearance was approved for four (4) ambulatory clients. All clients were attending the day program during inspection.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, garage, and back yard. The facility consists of four (4) total bedrooms and two (2) bathrooms. All indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 71 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 118.7 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Hand washing poster, paper towel, and soap observed at all hand washing stations. The supply of extra hygiene was available for residents. There is a minimum of 7-day non-perishables and 2-day perishables foods.

Smoke detectors/carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 10/4/2024. Emergency disaster plan last updated 12/19/2024. Fire drill last conducted 1/7/2025. First aid kit was observed to be complete.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2025
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: THOMAS HOME
FACILITY NUMBER: 079201011
VISIT DATE: 01/10/2025
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Continued from LIC809.

Four (4) staff and all six (6) client records were reviewed, current, and complete. LPA reviewed P&I.

The following forms to be updated and submitted to CCLD by 1/17/2025:
  • LIC610D Emergency disaster plan. (last page)
  • Surety Bond
  • LIC500 (Personnel Record)
  • LIC308 (Designation of facility Responsibility)
  • LIC400 Affidavit Regarding Client/Resident Cash Resources



No deficiencies cited during visit.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025
LIC809 (FAS) - (06/04)
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