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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201118
Report Date: 11/05/2021
Date Signed: 11/05/2021 12:06:38 PM

Document Has Been Signed on 11/05/2021 12:06 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:LEE FAMILY CARE HOMEFACILITY NUMBER:
079201118
ADMINISTRATOR:LEE, MAUREENFACILITY TYPE:
735
ADDRESS:2316 MEREDITH WAYTELEPHONE:
(925) 354-2254
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 6CENSUS: 6DATE:
11/05/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Maureen Lee, AdministratorTIME COMPLETED:
12:20 PM
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On 11/05/2021 at 9:40 AM, Licensing Program Analysts (LPAs) C. Lin and L. Francisco arrived unannounced to conduct Pre-licensing required inspection. LPAs met with Administrator, Maureen Lee and explained the purpose of the visit. Fire clearance is approve for ambulatory only. The facility currently has 6 clients.

LPAs toured facility including but not limited to 3 bedrooms, 2 bathrooms, kitchen, common areas and backyard. Bedrooms and living rooms were equipped with the proper furniture. Linens and hygiene supplies were observed inside a cabinet. There is sufficient lighting throughout facility. Room temperature was maintained at 72 degrees F and hot water temperature was maintained at 110 degrees F. First-aid kits were observed to be completed. Smoke detectors and carbon monoxide were operational. Fire extinguisher was last serviced on 6/2/2021.


Component III is waived. No issues noted during inspection. LPAs observed 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 provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2021
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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