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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201121
Report Date: 10/27/2022
Date Signed: 10/27/2022 03:03:41 PM

Document Has Been Signed on 10/27/2022 03:03 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 HOME #3FACILITY NUMBER:
079201121
ADMINISTRATOR:LEE, MAUREENFACILITY TYPE:
735
ADDRESS:3404 HEATHER RDTELEPHONE:
(925) 354-2254
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 6CENSUS: 3DATE:
10/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Ronald Sauler, CaregiverTIME COMPLETED:
03:10 PM
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On 10/27/2022 at 2:05PM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Infection Control Inspection. LPA met with Ronald Sauler, Caregiver, and explained the purpose of the visit. LPA spoke with Administrator, Maureen Lee whcm arrived at

Upon entry, LPA's temperature was not checked. Administrator explained why screening station isn't set up and COVID-19 signs not posted. Visitors and staff logs are in file cabinet. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, back yard, kitchen, and garage. All hand washing stations were equipped with soap and paper towel. Hand washing posters were posted at hand washing stations. Hot water temperature in the shared clients’ bathroom was measured at 109.1 degrees Fahrenheit. Fire extinguisher purchased on 6/17/2022. There is a minimum of 7-day non-perishables and 2-day perishables foods.

During record review, LPA observed facility has a copy of the infection control plan on file. LPA observed PPE, food, and paper supplies are sufficient.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 #3
FACILITY NUMBER: 079201121
VISIT DATE: 10/27/2022
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Continued from LIC809.

The following forms are to be updated and submitted to CCLD by 11/3/2022:

-LIC500 Personnel Report
-LIC308 Designation of Administrative Responsibility
-LIC610D Emergency Disaster Plan

No deficiencies cited during visit.

Exit interview and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022
LIC809 (FAS) - (06/04)
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