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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201120
Report Date: 06/07/2024
Date Signed: 06/07/2024 02:46:31 PM

Document Has Been Signed on 06/07/2024 02:46 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:LEE FAMILY CARE HOME #5FACILITY NUMBER:
079201120
ADMINISTRATOR/
DIRECTOR:		TUCKER, WILLIAMFACILITY TYPE:
735
ADDRESS:186 PISTACHIO PLACETELEPHONE:
(925) 354-2254
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 6CENSUS: 6DATE:
06/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:18 PM
MET WITH:William Tucker, Administrator TIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On 06/07/2024 at 12:18PM, Licensing Program Analyst (LPA)T. Syess-Gibson arrived to conducted an unannounced annual 1-year required inspection. At 12:25PM LPA called Administrator, Maureen Lee. At 12:50PM William Tucker, Administrator arrived, LPA explained the purpose of the visit. Administrator, William Tucker arrived at 12:50PM. The administrator currently holds a certificate (#7014915735) that expires on 02/02/2026. The facility’s fire clearance was approved for six (6) ambulatory clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, garage, and back yard. The facility consists of five (5) total bedrooms and two and half (2 1/2) bathrooms. One (1) bedroom used by staff. All indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 72 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 120.5 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Paper towel, and soap observed at all hand washing stations. The supply of extra hygiene was available for residents. There is a minimum of 7-day non-perishables and 2-day perishables foods.

Smoke detectors/carbon monoxide were in operating condition during visit. Fire extinguisher was last services on 07/15/2023. Fire drill last conducted 02/01/2024. First aid kit was observed to be complete.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: LEE FAMILY CARE HOME #5
FACILITY NUMBER: 079201120
VISIT DATE: 06/07/2024
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Continued from LIC809.

Three (3) staff records were reviewed, and all staff have first aid certification. All Three (3) clients' records reviewed, current, and complete. LPA reviewed a sample of medication and P & I.

The following forms to be updated and submitted to CCLD by 06/07/2024:

· Liability insurance.
· Surety Bond
· LIC500 (Personnel Record)
· Client Roster
· LIC308 (Designation of facility Responsibility)
· LIC400 Affidavit Regarding Client/Resident Cash Resources
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No deficiencies cited during visit.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024
LIC809 (FAS) - (06/04)
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