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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201023
Report Date: 03/19/2024
Date Signed: 03/19/2024 03:25:31 PM

Document Has Been Signed on 03/19/2024 03:25 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:CAP-ANTIOCHFACILITY NUMBER:
079201023
ADMINISTRATOR:AIMEE VITUG-HOMFACILITY TYPE:
775
ADDRESS:2157 COUNTRY HILLS DRIVETELEPHONE:
(925) 370-1818
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 50CENSUS: 18DATE:
03/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Kaitlin Thammalangsy, Program CoordinatorTIME COMPLETED:
03:35 PM
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On 3/19/2024 at 12:20pm, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Annual 1-year required inspection. LPA met with Kaitlin Thammalangsy, Program Coordinator, and explained the reason for the visit. The facility's fire clearance was approved for 40 ambulatory and 10 non-ambulatory clients.

LPA inspected the facility which included but not limited to the bathrooms, kitchen, common areas, and the outside area of the facility. LPA observed the facility to be free of odor, clean and in good repair. Outdoor space is provided and is free of hazards. There is a comfortable room temperature of 73 degrees Fahrenheit for clients in care. Grab bars mats were observed in bathrooms and throughout the facility. Clients bring their own lunches and snacks to facility. The hot water temperature in the shared bathroom measured 105.1 degrees. All observed toilets and hand washing stations are maintained in a safe, sanitary, operating condition. There are no bodies of water or fire safety hazards observed. Carbon monoxide and smoke detectors found to be in working order. Centrally stored medications, toxins and sharp objects were locked and inaccessible to clients.

Fire extinguisher last serviced on 9/15/2023. Fire drill last conducted 1/8/2024. Emergency disaster plan last updated 7/24/2023. First aid kit was checked and is complete.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2024
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: CAP-ANTIOCH
FACILITY NUMBER: 079201023
VISIT DATE: 03/19/2024
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Continued from LIC809.

LPA reviewed five (5) staff files and all are current and complete. LPA reviewed five (5) client files and were current and complete. The physician's reports were all outdated.

The following forms to be updated and submitted to CCLD by 3/26/2024:
  • LIC 308 Designation of Administrative Responsibility
  • LIC 610D Emergency Disaster Plan (last page)

No deficiencies were cited during this inspection.

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

DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024
LIC809 (FAS) - (06/04)
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