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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201043
Report Date: 03/24/2022
Date Signed: 03/24/2022 02:23:44 PM

Document Has Been Signed on 03/24/2022 02:23 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:D + V ENHANCEMENT SERVICESFACILITY NUMBER:
079201043
ADMINISTRATOR:TING, VICKY S.FACILITY TYPE:
775
ADDRESS:4851-B LONE TREE WAYTELEPHONE:
(925) 813-1979
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY: 50CENSUS: 10DATE:
03/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Vicki Ting, AdministratorTIME COMPLETED:
02:30 PM
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On 03/24/22 at 12:15PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an infection control annual inspection and explained the purpose of the visit with administrator. LPA observed 5 staff wearing face masks during visit. LPA observed 2 non-ambulatory clients watching an exercise video in the common hall. Facility has a mitigation plan in place dated 04/21/21 to mitigate the spread of COVID-19. LPA discussed the completed mitigation plan (LIC 808) with administrator as well as COVID-19 infection control practices.

One central entry point has been designated for universal entry screening with the station located near the front entrance with visitor's log, hand sanitizer, gloves, face masks and no touch temperature probe. COVID-19 signs are posted throughout the facility to promote handwashing, cough/sneeze etiquette and physical distancing. Facility documents daily temperatures and COVID-19 symptom checks for staff and clients. Pathways were observed to be free of obstruction and fire hazards.

A written Emergency/Disaster plan dated 04/01/21 was posted near the conference room. Centrally stored medications were locked in the medication room. Sharp objects were locked in the kitchen cabinet. Toxic chemicals were locked in the storage room.

Continued on next page LIC 809-C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2022
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: D + V ENHANCEMENT SERVICES
FACILITY NUMBER: 079201043
VISIT DATE: 03/24/2022
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Infection control designated leader is the administrator. All staff and clients have been fully vaccinated since February 2021. Facility room temperature was maintained at 72 degrees Fahrenheit. Clients' bathrooms were observed to have COVID-19 signages (how to wash hands properly) and had sufficient liquid soap/paper towels. Administrator is on site a minimum of 20 hours a week to oversee proper business operation and compliance with COVID-19 infection control practices. Fire extinguisher was fully charged and last inspected on 02/08/22. Smoke and Carbon monoxide detectors were operational.

Adequate supplies of PPE were also observed stored in the medication room. Facility follows daily cleaning, sanitation of frequently touched common surfaces using Clorox and Lysol disinfectants.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 03/25/22:
· LIC500- Personnel Report
· LIC308- Designation of Facility Responsibility
· LIC610E- Emergency/Disaster Plan
· Evidence of Liability Insurance

No deficiencies cited during this visit. Exit interview conducted and a copy of this report provided to administrator.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2022
LIC809 (FAS) - (06/04)
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