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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201207
Report Date: 12/08/2022
Date Signed: 12/08/2022 06:47:48 PM

Document Has Been Signed on 12/08/2022 06:47 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:PHOENIX RESIDENTIAL HOMEFACILITY NUMBER:
079201207
ADMINISTRATOR:CHAVEZ, CYNTHIAFACILITY TYPE:
735
ADDRESS:2009 RUBYE DRIVETELEPHONE:
(925) 852-8023
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 4CENSUS: 2DATE:
12/08/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
06:10 PM
MET WITH:Cynthia Chavez, Administrator/LicenseeTIME COMPLETED:
06:50 PM
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On 12/8/2022 at 6:10PM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct Pre-licensing inspection. LPA met with Cynthia Chavez, Administrator/Licensee and explained the purpose of the visit. Facility has fire clearance for four (4) ambulatory clients.

LPA 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 three (3) 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 75.6 degrees Fahrenheit. Fire extinguisher last serviced on 9/14/2022. Facility has locked cabinet for medications and sharps. Smoke/carbon Monoxide detectors are equipped and operable around the facility. First Aid kit was complete.

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: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2022
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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