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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201028
Report Date: 12/03/2020
Date Signed: 12/03/2020 12:46:12 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 CAREFACILITY NUMBER:
079201028
ADMINISTRATOR:PERRY, PALMER JASONFACILITY TYPE:
740
ADDRESS:2404 SILVERADO DRIVETELEPHONE:
(925) 206-4561
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:6CENSUS: 0DATE:
12/03/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Jason Perry, Applicant/AdministratorTIME COMPLETED:
12:30 PM
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On 12/03/20 at 11:20AM, a component III presentation was completed by LPA D Panlilio during the Pre-licensing tele visit inspection with applicant/administrator Jason Perry.

LPA discussed with applicant the most common deficiencies found in residential care facilities for the elderly and how to address them. Applicant/administrator was not physically available to sign this report due to COVID-19 shelter in place order.

The applicant was also reminded by LPA of the statute that requires CCL to be notified within 5 business days of admitting their first resident. This notification may be done by phone, by mail, or by fax.

A copy of this report provided to applicant via email.
SUPERVISOR'S NAME: Rajind BasiTELEPHONE: (510) 286-4201
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (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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