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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201120
Report Date: 11/30/2021
Date Signed: 11/30/2021 11:27:57 AM

Document Has Been Signed on 11/30/2021 11:27 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:LEE FAMILY CARE HOME #5FACILITY NUMBER:
079201120
ADMINISTRATOR:TUCKER, WILLIAMFACILITY TYPE:
735
ADDRESS:186 PISTACHIO PLACETELEPHONE:
(925) 354-2254
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 6CENSUS: 6DATE:
11/30/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Maureen Lee, LicenseeTIME COMPLETED:
11:45 AM
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On 11/30/2021 starting at 9:10 AM, Licensing Program Analysts (LPAs) L. Francisco and J. Clancy-Czuleger arrived unannounced to conduct Pre-licensing Inspection. Upon arrival, LPAs were greeted by Mildred Jose. Licensee, Maureen Lee arrived at 10:00 AM. The facility is approved for ambulatory clients only.

LPAs toured facility including but not limited to bedrooms, 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 147 degrees F. First-aid kit was observed to be complete. Smoke detectors and carbon monoxide were operational. Fire extinguisher was last serviced on 5/2/2021.

Prior to licensure, the following shall be corrected:
-Adjust hot water temperature between 105 degrees F and 120 degrees F. LPAs will return to follow-up.

Exit interview conducted. Due to technical difficulties, a copy of this report provided via email.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Lizette Francisco
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2021
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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