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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201188
Report Date: 10/27/2022
Date Signed: 10/27/2022 12:39:27 PM

Document Has Been Signed on 10/27/2022 12:39 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:EL REY HOME, THEFACILITY NUMBER:
079201188
ADMINISTRATOR:HAMILTON, LORELLFACILITY TYPE:
740
ADDRESS:2717 EL REY STREETTELEPHONE:
(415) 601-0243
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 3CENSUS: 0DATE:
10/27/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:48 AM
MET WITH:Lorell Hamilton, ApplicantTIME COMPLETED:
12:50 PM
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On 10/27/22 at 10:48AM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an announced pre-licensing visit and met with Lorell Hamilton, applicant. LPA explained the purpose of the visit with the applicant.

LPA toured the facility inside and outside including but not limited to resident's bedrooms, bathrooms, dining room, common living areas, kitchen, and outside patios. There is sufficient lighting around the facility. Resident's rooms were equipped with the proper furniture and lighting. Resident's rooms had proper bedding and linens for the residents. Bathroom was equipped with grab bars, nonskid mat, and hygiene items. Living room is equipped with the proper furniture for the residents. All toxins and sharp objects were locked. Passageways and hallways were free of obstruction. Fire extinguishers are observed fully charged. Dual smoke detectors/carbon monoxide were observed operational. Medication cabinet was locked and first aid kit was complete. All exit doors in the facility are equipped with auditory signals. Hot water temperature is measured at 118 degrees Fahrenheit. This is a brand new facility and perishable / nonperishable food supplies will be available when facility starts admitting residents. LPA observed the facility had the necessary posters in place (COVID signages, Ombuds & complaint poster).

Component III was conducted with the applicant.

No deficiencies were observed during inspection. LPA observed the facility is ready to be licensed. However, this report will be submitted to the central application 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: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2022
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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