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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201171
Report Date: 07/11/2024
Date Signed: 07/11/2024 01:13:19 PM

Document Has Been Signed on 07/11/2024 01:13 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:SUPPORT ADULT RESIDENTIAL, INCFACILITY NUMBER:
079201171
ADMINISTRATOR/
DIRECTOR:		MORENO, ELSYFACILITY TYPE:
735
ADDRESS:2028 RASEDA WAYTELEPHONE:
(925) 303-6181
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 4CENSUS: 4DATE:
07/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Loida Gavilan, Licensee TIME VISIT/
INSPECTION COMPLETED:
01:20 PM
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On 7/22/2023 at 9:45am, Licensing Program Analyst (LPA) L. Hall conducted an unannounced annual 1-year required inspection. LPA met with Loida Gavilan, Licensee, and explained the purpose of the visit. The administrator currently holds a certificate (#6043285735) that expires on 11/18/2024. The facility’s fire clearance was approved for four (4) ambulatory clients. No clients present during inspection.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of four (4) 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 74 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 107.1 degrees Fahrenheit. All toilets, hand washing, and baths are safe, sanitary and in operating condition. The supply of extra hygiene was available for residents. There is a minimum of 7-day non-perishables and 2-day perishables foods.

Smoke detectors/carbon monoxide were in operating condition during visit. Fire extinguisher last serviced on 3/6/2024. Emergency disaster plan lasted updated 3/5/2024. Fire drill last conducted on 6/10/2024. First aid kit was observed to be complete.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2024
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: SUPPORT ADULT RESIDENTIAL, INC
FACILITY NUMBER: 079201171
VISIT DATE: 07/11/2024
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Continued from LIC809.

Four (4) staff records were reviewed and complete. All four (4) clients records reviewed, current, and complete. LPA also reviewed P & I.

The following forms to be updated and submitted to CCLD by 07/18/2024:
  • LIC 400 Affidavit Regarding Client/Resident Cash Resources
  • LIC 402 Surety Bond
  • LIC 610D Emergency disaster plan (last page)
  • LIC 308 (Designation of facility responsibility)


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: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024
LIC809 (FAS) - (06/04)
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