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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201150
Report Date: 02/10/2022
Date Signed: 02/10/2022 12:35:05 PM

Document Has Been Signed on 02/10/2022 12:35 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:CONNECTED LIVING ANTIOCH IIFACILITY NUMBER:
079201150
ADMINISTRATOR:TRAIL, SARAFACILITY TYPE:
735
ADDRESS:2350 GALLOWAY 1/2 CTTELEPHONE:
(925) 826-6830
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY: 2CENSUS: 0DATE:
02/10/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Sara Trail, AdministratorTIME COMPLETED:
12:38 PM
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At 11AM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced pre-licensing visit and met with applicant. LPA explained the purpose of the visit with applicant.

Facility has an approved fire clearance dated 01/19/2021 for 2 residents. There are 2 bedrooms and 1 bathroom. Posters including but not limited to Covid19 related posters, complaint poster, Personal Rights were observed. All bedrooms were observed furnished with a bed, dresser, closet, nightstand, lamp and chair. Passageways inside and outside were free of obstruction. There was sufficient lighting and furniture. The kitchen was observed clean and organized. There was sufficient supply of non-perishable foods observed. Plates, silver wares and glass wares were observed available. A copy of menu was posted on the refrigerator. Hot water measured at 119 F. There were locked cabinets for medicine, chemicals and resident files. Knives and other sharp objects were kept in a locked drawer in the kitchen. There was sufficient supply of towels, sheets, blankets and hygiene products observed. LPA observed at least 30 days supply of PPEs and paper products.

Smoke detector and carbon monoxide were tested and observed operational. First aid kit was complete. There were activity materials available. Facility has a washer and dryer next to the living room area. LPA observed chairs and tables in the covered gazebo for use by clients. The swimming pool has a locked gate with 7 foot black metal fence all around the perimeter.

LPA observed that facility is ready to be licensed. This report will be submitted to the Central Applications Branch (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required.

Exit interview conducted and a copy of this report was provided to Applicant via email.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2022
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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