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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201118
Report Date: 06/21/2023
Date Signed: 06/21/2023 01:25:33 PM

Document Has Been Signed on 06/21/2023 01:25 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:
06/21/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Maureen Lee, AdministratorTIME COMPLETED:
01:35 PM
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On 6/21/2023 at 12:05 Licensing Program Analyst (LPA) L. Hall conducted an unannounced Case Management visit regarding an incident report received for Client 1 (C1). LPA met with Administrator, Maureen Lee, and explained the purpose of the visit.

Incident report sent on 06/14/2023 was for an AWOL. Staff 1 (S1) stated that C1 was determined by Regional Center of the East Bay (RCEB) that C1 can go out into the community without supervision. LPA reviewed physician’s report dated 5/4/2023 states that C1 can leave unsupervised.

S1 called C1’s RCEB case manager, Q & A Specialist, and the behaviorist during visit. All stated during the calls that C1 can leave unsupervised if C1 takes his medication and is stable. S1 along with the case manager, Q &A Specialist and the behaviorist will have an emergency Interdisciplinary Team meeting (IDT) to implement a plan to help keep C1 safe in the community.

LPA requested the following documents to be submitted by 6/23/2023: client roster, personnel record (LIC500), physician’s report (LIC602), house rules, admission agreement, and the individual program plan (IPP).

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2023
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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