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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201071
Report Date: 04/18/2023
Date Signed: 04/18/2023 02:41:36 PM

Document Has Been Signed on 04/18/2023 02:41 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:PICADILLY HOME CAREFACILITY NUMBER:
079201071
ADMINISTRATOR:SANTOS, CHARLIEFACILITY TYPE:
735
ADDRESS:1221 PICADILLY LANETELEPHONE:
(925) 849-7743
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 4CENSUS: 3DATE:
04/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Charlie Santos, Administrator TIME COMPLETED:
03:00 PM
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On 4/18/2023 at 10:00AM Licensing Program Analyst (LPA) L. Ibo arrived unannounced to conduct an annual required inspection. LPA met with Administrator Charlie Santos and Backup Administrator Mathew Tobias. Facility has census of 3. LPA observed three (3) clients and two staff with Administrator at the facility.

LPA toured the entire premises indoors and outdoors with Charlie Santos, including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility has 4 bedrooms including master bedroom, 2 bathrooms including master bathroom, two story house per facility sketch. Three bedrooms are designated for clients’ master bedroom is designated for staff. LPA observed 2 fire extinguishers which was in the kitchen and second floor of the home adjacent to bedroom #3. Smoke detectors and carbon monoxide detectors were observed operational. The facility received a fire clearance dated 03/18/2021 with an approval for a total capacity of 4 clients, approved for ONLY 4 ambulatory residents.

Facility has enough supplies of PPEs, paper supplies and hygiene supplies. Facility has a mitigation plan and infection control plan.

There was sufficient supply of perishable and non-perishable foods observed. LPA interviewed 2 staff and interviewed two (2) out of 3 clients. First aid kit was observed complete. Freezer temperature was observed at 0 degrees Fahrenheit. Refrigerator temperature measured at 37 degrees Fahrenheit.

No deficiency cited during the visit; however a technical violation was provided to Administrator.

Exit interview conducted. Appeal Rights and copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2023
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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