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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201044
Report Date: 03/01/2021
Date Signed: 03/01/2021 07:51:57 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:DEER RIDGE COUNTRY VILLAFACILITY NUMBER:
079201044
ADMINISTRATOR:SALAZAR, HENRYFACILITY TYPE:
740
ADDRESS:419 DEL MONTE COURTTELEPHONE:
(925) 997-7354
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:6CENSUS: 0DATE:
03/01/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
06:00 PM
MET WITH:Paul Henry Salazar, Applicant/AdministratorTIME COMPLETED:
07:45 PM
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While at the facility conducting a Pre-Licensing inspection, Licensing Program Analyst (LPA) Praveen Singh conducted a Component III Orientation with Applicant/Administrator Paul Henry Salazar. Due to the Governor's present shelter in place order, this inspection was completed via video-conference.

During the inspection, Applicant/Administrator was provided with information to operate the facility within Title 22 regulatory compliance, as well as how to avoid common problem areas. Component III does not cover ALL regulations, only those found to be most problematic. Regulations require Administrator to be knowledgeable of all regulations and amendments to law.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Praveen SinghTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2021
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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