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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201171
Report Date: 06/29/2022
Date Signed: 06/29/2022 10:43:10 AM

Document Has Been Signed on 06/29/2022 10:43 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:SUPPORT ADULT RESIDENTIAL, INCFACILITY NUMBER:
079201171
ADMINISTRATOR:MORENO, ELSYFACILITY TYPE:
735
ADDRESS:2028 RASEDA WAYTELEPHONE:
(925) 303-6181
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 4CENSUS: 0DATE:
06/29/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Loida Gavilan, Assistant AdministratorTIME COMPLETED:
10:50 AM
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On 6/29/2022 at 09:35 AM, Licensing Program Analysts (LPAs) L. Hall and C. Fowler arrived announced to conduct Pre-licensing inspection. LPAs met with Loida Gavilan, Assistant Administrator, and explained the purpose of the visit. Elsy Moreno, Administrator, arrived at 09:52AM.

LPAs inspected the facility inside and out including but not limited to the bedrooms, bathrooms, common living areas, kitchen, garage and back yard. The facility has a total of four (4) bedrooms and two (2) bathrooms There is sufficient lighting around the facility. Clients rooms are equipped with the beds, chairs, and lighting. Clients' rooms have proper bedding and linens. Passageways and hallways are free of obstruction. Hot water temperature is measured at 110.2 degrees Fahrenheit. Fire extinguisher last serviced on 3/16/2022. Smoke detectors/carbon Monoxide detector are equipped around the facility. First aid kit is complete.

Licensing Program Manager (LPM), H. Humpal gave approval to waive the Comp III.

No Issues were noted during inspection. LPA observed that facility is ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAU. Additional requirements may still be required.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 06/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/29/2022
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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