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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201199
Report Date: 08/11/2022
Date Signed: 08/11/2022 12:58:04 PM

Document Has Been Signed on 08/11/2022 12:58 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:LYN'S HOME LLCFACILITY NUMBER:
079201199
ADMINISTRATOR:OBSIOMA, MERLINDAFACILITY TYPE:
735
ADDRESS:2667 DOE COURTTELEPHONE:
(925) 890-9068
CITY:CONCORDSTATE: CAZIP CODE:
94519
CAPACITY: 4CENSUS: 0DATE:
08/11/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Merlinda Obsioma, Applicant/AdministratorTIME COMPLETED:
01:13 PM
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On 08/11/22 at 11:40 am, Licensing Program Analyst (LPA) J. Clancy-Czuleger arrived unannounced to conduct a Change of Location Pre-licensing Required inspection. LPA met with Applicant/Administrator Merlinda Obsioma and explained the purpose of the visit. The facility currently has no residents living at the facility. Fire clearance was granted on 03/02/2022. LPA observed COVID signs posted in the front entrance, common areas and bathrooms.

LPA inspected the facility inside out. There is no body of water. Physical plant is consistent with the facility sketch received by Central Application Bureau (CAB) and approved by the fire department. LPA inspected 4 resident bedrooms, 2 staff rooms, 2 bathrooms, kitchen, common areas and backyard. Bathrooms were equipped with grab bars and shower mats. Linens and hygiene supplies were observed inside hallway cabinets. There is sufficient lighting throughout facility. Equipment and supplies for residents' personal hygiene are available and on site. Dinner and silver wares were observed sufficient for residents' use. Food supplies checked and observed good for seven days of non-perishables. Facility was observed equipped with refrigerator, microwave, dishwasher, washer and dryer. Cabinet for knives, cleaning supplies, and central storage for medications were observed with locks. Activity supplies were available. Outdoor activity space was observed furnished with tables, chairs and shade. Hot water temperature was maintained at 114.4 degrees F. Smoke detectors and carbon monoxide were operational. Pathways inside and outside were free of fire hazards and obstruction. Fire extinguisher were shown to be brand new.


No deficiencies were observed during visit. Facility is ready to be licensed. This report will be submitted to the Central Applications Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required.

Exit interview conducted and a copy of this report provided via email.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE: DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/11/2022
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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