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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201158
Report Date: 04/18/2024
Date Signed: 04/18/2024 11:50:06 AM

Document Has Been Signed on 04/18/2024 11:50 AM - 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/
DIRECTOR:		MARTINEZ, JORGE AFACILITY TYPE:
735
ADDRESS:57 RUSSELL DR.TELEPHONE:
(925) 597-0726
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 4CENSUS: 1DATE:
04/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Ana Colunga, Direct Support ProfessionalTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 4/18/2024 at 10:00am, Licensing Program Analysts (LPAs) L. Hall and L. Holmes conducted an unannounced annual required inspection. Direct Support Professional, Ana Colunga, arrived at 10:30am. LPAs explained the purpose of the visit. The administrator currently holds a certificate (#6060404735) that expires on 7/25/2025. 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, garage, and back yard. The facility consists of three (3) bedrooms and two (2) 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 71 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 106.3 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 supply of non-perishable and 2-day of perishable foods.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2024
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: SUBLIME ARF #1
FACILITY NUMBER: 079201158
VISIT DATE: 04/18/2024
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Continued from LIC9099.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was purchased on 5/2/2023. Emergency Disaster Plan was last posted on 2/10/2024. First aid kit was observed to be complete. Fire drill was last conducted on 3/12/2024.

LPA reviewed four (4) staff records all were current and complete and client's record. LPA also review P & I and a sample of medication.

The following forms to be updated and submitted to CCLD by 4/25/2024:
  • LIC 500 Personnel Report
  • LIC 400 Affidavit Regarding Client/Resident Cash Resources
  • LIC 402 Surety Bond
  • LIC610D Emergency disaster plan (last page)
  • LIC308 Designation of facility responsibility

No deficiencies cited during visit.

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

DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
LIC809 (FAS) - (06/04)
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