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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201023
Report Date: 03/01/2023
Date Signed: 03/01/2023 11:09:03 AM

Document Has Been Signed on 03/01/2023 11:09 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: 17DATE:
03/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Dawn Robinson, Program DirectorTIME COMPLETED:
11:20 AM
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On 3/1/2022 at 9:50AM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Infection Control Inspection. LPA met with Dawn Robinson, Program Director, and explained the purpose of the visit.

Upon entry, LPA's temperature was checked. LPA observed screening station that contained hand sanitizer and sign-in log. LPA toured facility including but not limited to common areas, bathrooms, kitchen and back sitting area. All hand washing stations were equipped with soap, and paper towel, and hand washing poster. Fire extinguishers last serviced 10/25/2022. LPA was not able to measure hot water temperature in the shared clients’ bathroom measured at 111.5 degrees F.

During record review, LPA observed facility has a copy of the Infection Ctonrol Plan on file. LPA observed PPE and paper supplies are sufficient.

The following forms are to be updated and submitted to CCLD by 3/8/2023:
  • Updated documents to change Administrator/Program Director

No deficiencies cited during visit.

Exit interview conduct and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/01/2023
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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