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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201120
Report Date: 12/01/2022
Date Signed: 12/01/2022 11:14:01 AM

Document Has Been Signed on 12/01/2022 11:14 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:
12/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:William Tucker, Administrator & Maureen Lee, backup AdministratorTIME COMPLETED:
11:35 AM
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On 12/1/2022 at 9:50 AM Licensing Program Analyst (LPA) Leslie Ibo arrived unannounced to conduct an annual required inspection. LPA met with backup Administrator Maureen Lee and Administrator William Tucker. Facility has census of 6.

LPA toured the facility with Maureen Lee, including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. A comfortable temperature is maintained at 75 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Visitors policy is posted on the front entrance. Clients bathrooms are equipped with grab bars and non-skid mats. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods. Medications are centrally stored in a locked area that is inaccessible to clients and refilled every at least 30 days. Smoke detectors and carbon monoxide were in operating condition during visit.

Facility has enough supplies of PPEs, paper supplies and hygiene supplies. There is one central entry point for universal screening for staff, clients and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has infection control plan and maintains record of routine screening for residents and staff.

No deficiency cited during the visit.

Exit interview conducted. Appeal Rights and copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/01/2022
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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