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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201123
Report Date: 12/20/2022
Date Signed: 12/20/2022 12:23:52 PM

Document Has Been Signed on 12/20/2022 12:23 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 #4FACILITY NUMBER:
079201123
ADMINISTRATOR:TUCKER, WILLIAMFACILITY TYPE:
735
ADDRESS:18 BROOKS CTTELEPHONE:
(925) 354-2254
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 6CENSUS: 5DATE:
12/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:William Tucker, Administrator and Maureen Lee, backup Administrator TIME COMPLETED:
12:35 PM
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On 12/20/2022 at 10:00 AM Licensing Program Analyst (LPA) Leslie Ibo arrived unannounced to conduct an infection control annual inspection. LPA met with Administrator William Tucker and backup Administrator Maureen Lee. Facility has census of 5. There was no client observed during the LPA visit, per Administrator and backup Administrator, all clients are out working, and others are in day program.

LPA toured the facility with Maureen Lee, including but not limited to the living room, dining area, kitchen, bedrooms, hallways, bathrooms, side and backyards. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 71 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Visitors policy is posted on the front entrance. 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, residents 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 (mask). Facility has a mitigation plan an infection control plan was received and reviewed during the visit. Facility 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: 12/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2022
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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