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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201102
Report Date: 10/13/2021
Date Signed: 10/13/2021 05:16:03 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:DYSICO CARE HOME, RCFEFACILITY NUMBER:
079201102
ADMINISTRATOR:LEKSE, EVANGELINEFACILITY TYPE:
740
ADDRESS:461 TURRIN DRIVETELEPHONE:
(925) 270-3081
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY:6CENSUS: 4DATE:
10/13/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:EVANGELINE LEKSETIME COMPLETED:
05:30 PM
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Licensing Program Analyst (LPA) James Sampair conducted an unannounced pre-licensing inspection and met with Administrator, Evangeline Lekse. LPA explained the reason for the visit. LPA observed 2 of the 2 staff wearing masks. LPA also observed 4 residents resting in their bedrooms during the visit.

In this follow up of the initial 10/07/21 pre-licensing visit, the LPA again toured the facility inside and outside, including but not limited to resident's bedrooms, bathrooms, dining room, common living areas, kitchen, and outside patios. No reduction in the standard of care nor in the cleanliness and orderliness of the physical plant has occurred.

The LPA also saw proof that the Applicant, Josephine Dysico, has completed all of the necessary changes identified on 10/07/21: adequate emergency lighting in easily accessible locations, updates to the Emergency and Disaster Plan, and an LIC 999 Facility Sketch of the Yard with a Resident Assembly Point on it. With those changes in place at the facility, this report is ready to be submitted to the central application unit (CAU), where 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 provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021
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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