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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201100
Report Date: 10/27/2021
Date Signed: 10/27/2021 12:56:37 PM

Document Has Been Signed on 10/27/2021 12:56 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:LIFESPRING HOMEFACILITY NUMBER:
079201100
ADMINISTRATOR:OGLOBOSELE, ANNEFACILITY TYPE:
735
ADDRESS:3711 LINDERO DRIVETELEPHONE:
(510) 451-0785
CITY:CONCORDSTATE: CAZIP CODE:
94519
CAPACITY: 4CENSUS: 0DATE:
10/27/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Anne Oglobosele/Applicant-Administrator and
Clifford Oglobosele/Applicant-Licensee		TIME COMPLETED:
01:00 PM
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Licensing Program Analysts (LPAs) Alicia Delmundo and Jill Clancy-Czuleger conducted an announced pre-licensing inspection. License application is for four (4) total capacity, of which 1 maybe non-ambulatory. Fire clearance was granted on August 10, 2021. LPAs met with Anne Oglobosele (applicant-administrator) and Clifford Oglobosele (applicant-licensee).

LPAs inspected the facility inside out. There is no body of water. Physical plant is consistent with the facility sketch received by Central Application Bureau (CAB) and approved by the fire department. LPAs inspected the living room, dining area, kitchen, bedrooms, hallways, bathrooms, side and backyards. Bedrooms were observed appropriately furnished with adequate lighting and drawers. Facility has sufficient towels, extra bed sheets and comforters. Equipment and supplies for residents' personal hygiene are available and on site. Dinner and silver wares were observed sufficient for residents' use. Food supplies checked and observed good for seven days of non-perishables. Facility was observed equipped with refrigerator, microwave, dishwasher, washer and dryer. Cabinet for knives, cleaning supplies, and central storage for medications were observed with locks. Activity supplies were available. Outdoor activity space was observed furnished with tables, chairs and shade.

Fire extinguishers were observed fully charge and tags showed serviced July 15, 2021. The two-in-one carbon monoxide and smoke detector tested and observed functional. First aid kit checked and observed complete with manual. Hot water temperature in one of the bathrooms tested and measured at 117.4 degrees Fahrenheit.


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SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: LIFESPRING HOME
FACILITY NUMBER: 079201100
VISIT DATE: 10/27/2021
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LPAs observed the following:
1. No Theft and Loss Policy and complaint poster.
2. Trash bins with no lids.
3. Paper towesl in the bathrooms with no holders.
4. Personal Protective Equipment (PPE) supplies not sufficient for 30 days.

LPAs discussed the following:
1. Requirement for N95 fit testing of staff.
2. Setting up a central screening area by the entrance door

LPA Delmundo requested for LIC808 Mitigation Plan which LPA received on October 25, 2021. Revision/updating of page #'s 3 and 28 isneeded. Updated copy to be submitted by November 10, 2021.

Upon receipt of the LIC808 Mitigation Plan, proof of corrections for the 4 items above, proof ot N95 fit testing and picture of central screening area by November 10, 2021, LPA Delmundo will inform CAB. Issuance of license is pending upon final review by CAB analyst.

Exit interview conducted and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2