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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201158
Report Date: 04/21/2023
Date Signed: 04/21/2023 03:01:17 PM

Document Has Been Signed on 04/21/2023 03:01 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:SUBLIME ARF #1FACILITY NUMBER:
079201158
ADMINISTRATOR:MARTINEZ, JORGE AFACILITY TYPE:
735
ADDRESS:57 RUSSELL DR.TELEPHONE:
(925) 597-0726
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 4CENSUS: 0DATE:
04/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Gloria Martinez, Direct Support ProfessionalTIME COMPLETED:
03:10 PM
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On 4/20/2023 at 12:40PM, Licensing Program Analysts (LPAs) L. Hall and L. Alexander conducted an unannounced annual 1-year required inspection. LPAs met with Gloria Martinez, Direct Support Professional (DSP), and explained the purpose of the visit. LPA spoke with Administrator, Jorge Martinez via telephone. LPA toured the facility with DSP Ana Colunga Rezendiz. The administrator currently holds a certificate (#6060404735) that expires on 07/25/2023. The facility’s fire clearance was approved for four (4) ambulatory clients. Facility does not have any clients. Facility is not operating.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of three (3) total bedrooms and two (2 ) bathrooms. All indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 68 degrees Fahrenheit. LPA 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 106.0 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. PPE and paper goods are sufficient. There is a minimum of 7-day non-perishables and 2-day perishables foods.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 04/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/21/2023
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: SUBLIME ARF #1
FACILITY NUMBER: 079201158
VISIT DATE: 04/21/2023
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Continued from LIC809.

Smoke detectors/carbon monoxide were in operating condition during visit. Fire extinguisher last serviced on 2/10/2022. First aid kit was observed to be complete.

The following forms to be updated and submitted to CCLD by 04/28/2023:
  • LIC 400 Affidavit Regarding Client/Resident Cash Resources
  • LIC 402 Surety Bond
  • LIC 610D Emergency disaster plan
  • Liability insurance.


No deficiencies cited during inspection.

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

DATE: 04/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023
LIC809 (FAS) - (06/04)
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