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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201023
Report Date: 03/21/2022
Date Signed: 03/21/2022 11:26:55 AM

Document Has Been Signed on 03/21/2022 11:26 AM - 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:CAP-ANTIOCHFACILITY NUMBER:
079201023
ADMINISTRATOR:MCCRARY, CAROL ANNEFACILITY TYPE:
775
ADDRESS:2157 COUNTRY HILLS DRIVETELEPHONE:
(925) 370-1818
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 50CENSUS: 0DATE:
03/21/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Dawn, Program CoordinatorTIME COMPLETED:
11:45 AM
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On 03/21/22 at 10:35 a.am., Licensing Program Analyst (LPA) Greg Clark arrived announced to conduct pre-licensing inspection. LPA met with Program Coordinator Dawn Robinson and explained the purpose of the visit. The facility currently has no participates.

LPA toured facility including but not limited to: bathrooms, kitchen, common areas and activity rooms. All rooms were equipped with the proper furniture. Bathrooms were equipped with grab bars and non-skid mats. Hhygiene supplies were observed inside a cabinet. There is sufficient lighting throughout facility. Room temperature was maintained at 72 degrees F and hot water temperature was maintained at 105 degrees F. First-aid kit was observed to be complete. Smoke detectors and carbon monoxide were operational. Fire extinguisher was last serviced on 10/22/21.


No issues noted during inspection. LPAs observed that facility is ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed, and is subject to final approval by CAU. Additional requirements may still be required.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2022
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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