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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201023
Report Date: 03/04/2025
Date Signed: 03/04/2025 01:11:12 PM

Document Has Been Signed on 03/04/2025 01:11 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/
DIRECTOR:		AIMEE VITUG-HOMFACILITY TYPE:
775
ADDRESS:2157 COUNTRY HILLS DRIVETELEPHONE:
(925) 370-1818
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 50CENSUS: 26DATE:
03/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:20 AM
MET WITH:Kaitlin Thammalangsy, Program CoordinatorTIME VISIT/
INSPECTION COMPLETED:
01:20 PM
NARRATIVE
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On 3/4/2025 at 10:20pm, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an annual 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 111.0 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 9/5/2024. Fire drill last conducted 12/10/2024. Emergency disaster plan last updated 7/15/2024. First aid kit was checked and is complete.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2025
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: 03/04/2025
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Continued from LIC809.

LPA reviewed four (4) staff files and all are current and complete. One (1) staff file was not available for review. LPA reviewed six (6) client files and were current and complete.

The following forms to be updated and submitted to CCLD by 3/11/2025:
  • LIC 308 Designation of Administrative Responsibility
  • LIC 610D Emergency Disaster Plan (last page)

LPA observed the following deficiencies:
  • At 10:40am, LPA observed during record review S1 did not have a personnel record available for review.


Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

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

DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/04/2025 01:11 PM - It Cannot Be Edited


Created By: Laura Hall On 03/04/2025 at 12:48 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CAP-ANTIOCH
FACILITY NUMBER: 079201023

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82066(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator, and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in having S1's file available for review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/11/2025
Plan of Correction
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 Program Coordinator will submit a self-certification to CCLD by POC stating the facility will obtain S1's complete file to review.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2025


LIC809 (FAS) - (06/04)
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