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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 12:36:01 PM

Document Has Been Signed on 02/10/2022 12:36 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:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:26 PM
MET WITH:Sara Trail, AdministratorTIME COMPLETED:
01:10 PM
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On 02/10/22, while at the facility for another reason, Licensing Program Analyst (LPA) Daisy Panlilio went over the component III power point presentation with applicant and discussed the most common deficiencies cited for adult residential facilities and how to prevent them.

Applicant stated she will comply with Title 22 regulations and implement COVID 19 mitigation plan to mitigate the spread of the virus.

Exit interview conducted and a copy of this report provided by 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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