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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201122
Report Date: 01/12/2024
Date Signed: 01/12/2024 04:02:52 PM

Document Has Been Signed on 01/12/2024 04:02 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 #2FACILITY NUMBER:
079201122
ADMINISTRATOR:TUCKER, WILLIAMFACILITY TYPE:
735
ADDRESS:660 TIMBERLINE TERRACETELEPHONE:
(925) 354-2254
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 6CENSUS: 6DATE:
01/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:MAUREEN LEE LICENSEETIME COMPLETED:
04:50 PM
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On 01/12/2024 at 1:20PM, Licensing Program Analysts (LPAs)Carol Fowler and Tonica Syess-Gibson conducted an unannounced annual required inspection. LPAs met with Lizzeth Hernandez, Administrator, and explained the purpose of the visit. Licensee, Maureen Lee, arrived at 1:30PM. LPAs toured the facility with Licensee Maureen Lee. The facility’s fire clearance was approved for Six (6) ambulatory clients.

LPAs toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of four (4) total bedrooms and three (3) bathrooms. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 70 degrees Fahrenheit. LPAs 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 111.9 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Hand washing poster, 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.

Continued on LIC809C.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 01/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/12/2024
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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: LEE FAMILY CARE HOME #2
FACILITY NUMBER: 079201122
VISIT DATE: 01/12/2024
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Continued from LIC809.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 07/14/2023. Emergency Disaster Plan was last posted on 05/04/2023. First aid kit was observed to be complete. Fire drill was last conducted on 01/04/2024.

Three (3) staff records reviewed and complete. All Five (5) clients records reviewed, current, and complete. LPAs also reviewed P & I and medication.

The following forms to be updated and submitted to CCLD by 1/26/2024:

· LIC 500 Personnel Report
· LIC 400 Affidavit Regarding Client/Resident Cash Resources
· LIC 402 Surety Bond
· LIC610D emergency disaster plan (last page)
· Client roster
· LIC308 Designation of facility responsibility

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024
LIC809 (FAS) - (06/04)
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