079201028-12-3-2020-15-AS-DPAO-BVXRZ7-20201203122729

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079201028
Report Date: 12/03/2020
Date Signed: 12/03/2020 12:28:45 PM

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:	PERRY'S HOME CARE		FACILITY NUMBER:	079201028
ADMINISTRATOR:	PERRY, PALMER JASON		FACILITY TYPE:	740
ADDRESS:	2404 SILVERADO DRIVE		TELEPHONE:	(925) 206-4561
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94509
CAPACITY:	6	CENSUS: 0	DATE:	12/03/2020
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Jason Perry, Applicant/Administrator		TIME COMPLETED:	11:20 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 12/03/2020 at 10AM, Licensing Program Analyst (LPA) D. Panlilio conducted a Face Time tele-visit pre licensing inspection and met with applicant/administrator Jason Perry. LPA explained to applicant that this visit is being conducted via Face time in compliance with the shelter in place order of the governor. Applicant/administrator was not physically available to sign this report due to COVID-19 shelter in place order. LPA toured the facility indoors and outdoors. The facility is a 5 bedroom 3 bathroom single story house. All 5 bedrooms are designated for residents, one of which is a shared bedroom with an adjacent bathroom. There are 2 common bathrooms located near the 4 private bedrooms.Two fire extinguishers were observed fully charged located in the kitchen area. Smoke detectors are hardwired throughout the main floor and are equipped with carbon monoxide detection. All were tested and operational. The facility received a fire clearance with an approval for 5 non-ambulatory residents & 1 bedridden resident in Room # 5 based on the facility sketch. There was a locked area for medications in the dining area. The garage contained locked cabinets for storing toxins, detergents, cleaning supplies, gardening supplies, and tools. Beds were made with appropriate linens and additional linens were observed to be on hand inside a linen closet. Furniture and lighting were observed to be safe and adequate. Each bedroom was furnished with a bed, bedding, a night stand, a chair, and sufficient closet space. LPA advised applicant/ administrator that hot water temperature should be maintained between 105 degrees F and 120 degrees F. There were no bodies of water present at the facility. Outside pathways to security exit gate were unobstructed. LPA observed backyard has a shaded area with chairs and table for residents' use. First Aid kit was observed complete and current. Continued on next page, LIC 809-C

SUPERVISOR'S NAME: Rajind Basi	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2020

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: PERRY'S HOME CARE	FACILITY NUMBER: 079201028
	VISIT DATE: 12/03/2020

NARRATIVE

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LPA observed the facility had the necessary posters displayed on the bulletin board next to the front entrance (i.e. Emergency/Disaster Plan, Personal rights, State/Federal wage regulations, etc). Passageways and hallways were observed free of obstruction.

As this is a new facility, no residents were present during today’s visit. During today's visit, LPA reviewed LIC 610E Emergency disaster plan/Fire and Earthquake drill requirements with applicant/administrator as well as staff training & First Aid/CPR certifications.

No issues noted during the pre-licensing inspection. LPA observed the facility is ready to be licensed. However, this report will be submitted to the central application unit (CAU) in Sacramento CA 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.

SUPERVISOR'S NAME: Rajind Basi	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2020

LIC809 (FAS) - (06/04)

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