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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201101
Report Date: 09/13/2021
Date Signed: 09/13/2021 11:46:48 AM

Document Has Been Signed on 09/13/2021 11:46 AM - 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:ELIAS PLACEFACILITY NUMBER:
079201101
ADMINISTRATOR:RODRIGUEZ, RENEFACILITY TYPE:
735
ADDRESS:2355 GLENDALE CIRTELEPHONE:
(904) 859-1773
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 6CENSUS: 0DATE:
09/13/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Rene Rodriguez, ApplicantTIME COMPLETED:
11:30 AM
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On 09/13/21 at 10:15AM, Licensing Program Analyst (LPA) D. Panlilio conducted a pre licensing inspection and met with applicant Rene Rodriguez. LPA explained the purpose of the visit with applicant. The facility's fire clearance was approved for 6 ambulatory clients. Routine COVID-19 symptom checks were conducted by applicant at the front entrance screening station during visit.

LPA toured the facility with applicant including but not limited to the clients' bedrooms, common areas, kitchen, and outdoor area. The facility is a single story house with 4 bedrooms, 2 full bathrooms and 1 half bathroom. As this is a new facility, no clients were present during today’s visit. LPA verified there is a land line telephone in the facility, which is currently operating. During today's visit, LPA reviewed LIC 610D Emergency disaster plan/Fire and Earthquake drill requirements.

LPA observed COVID-19 signages in the front entrance, bathrooms and common areas. LPA observed adequate lighting inside with comfortable temperature at 72 degrees Fahrenheit per thermostat reading. There are designated individual locked storage cabinets for cleaning supplies, knives and medications found in the kitchen. Indoor and outdoor passageways were observed free of obstruction and fire hazards.

There were no bodies of water observed. Smoke and carbon monoxide detectors were observed operational. First aid kit was complete. Fire extinguisher was observed fully charged and last inspected on 07/21/21. Emergency/Disaster plan dated 08/06/21 was posted in the bulletin board. Refrigerator temperature was observed at 37 degrees Fahrenheit and freezer at 0 degrees Fahrenheit. Sharps, medications, toxic chemicals were observed locked.

Continued on next page, LIC-809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 09/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2021
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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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: ELIAS PLACE
FACILITY NUMBER: 079201101
VISIT DATE: 09/13/2021
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LPA advised applicant that hot water temperature should be maintained between 105 degrees F and 120 degrees F. LPA observed one week supply of perishable and 2 weeks supply of non-perishable foods. Towels, sheets, activity supplies and hygiene products were observed available.

LPA observed the shower area has non-skid floor mats. There are activity materials observed in the living room. The backyard has a shaded area with chairs and table for clients' use. The facility has a detached storage shed that will be used as storage space for tools and extra supplies per applicant.

LPA observed no deficiencies during inspection and that facility is ready to be licensed. This report will be submitted to the Central Applications unit (CAU) and a final review of the application will be conducted.

This facility is not yet licensed and is subject to final approval by CAU. Additional requirements may still be required. Exit interview conducted and a copy of this report was provided to applicant.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2021
LIC809 (FAS) - (06/04)
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