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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201099
Report Date: 04/18/2023
Date Signed: 04/18/2023 01:38:13 PM

Document Has Been Signed on 04/18/2023 01:38 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:GARCIA'S PLACE, INC.FACILITY NUMBER:
079201099
ADMINISTRATOR:OVILIO BARRIOS GARCIAFACILITY TYPE:
735
ADDRESS:1712 SAN JOSE DRIVETELEPHONE:
(925) 565-5731
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 4CENSUS: 4DATE:
04/18/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Victor Hernandez, Direct Support ProfessionalTIME COMPLETED:
01:45 PM
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On 4/18/2023 at 12:20PM Licensing Program Analyst (LPA) L. Hall conducted an unannounced Case Management follow-up visit regarding an incident that was reported to CCLD on 10/08/2022. LPA met with Victor Hernandez, Direct Support Professional and explained the purpose of the visit. Administrator, Ovilio Barrios Garcia arrived at 12:35PM.

During the visit LPA requested the following documents be submitted to CCLD by close of business day 4/18/2023: functional capability; appraisal needs and services plan; annual review dated 7/12/2022; 30-day post placement dated 9/18/2022; admission agreement; identification and emergency information; notification of individual high risk behavior and dangerous propensities dated 9/30/2022; medication record for September and October 2022; target behavior September and October 2022; case notes 8/24/2022 to 10/08/2022; sheet for community outings; and Individual Program Plan (IPP) addendums dated 8/22/2022; 8/31/2022, 9/7/2022, and 9/20/2022.

No citations are being issued on this date.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
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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