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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201207
Report Date: 12/07/2023
Date Signed: 12/07/2023 11:51:21 AM

Document Has Been Signed on 12/07/2023 11:51 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:PHOENIX RESIDENTIAL HOMEFACILITY NUMBER:
079201207
ADMINISTRATOR:CHAVEZ, CYNTHIAFACILITY TYPE:
735
ADDRESS:2009 RUBYE DRIVETELEPHONE:
(925) 778-8557
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 4CENSUS: 3DATE:
12/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Cynthia Chavez, AdministratorTIME COMPLETED:
12:00 PM
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On 12/7/2023 at 9:45pm, Licensing Program Analyst (LPA) L. Hall conducted an unannounced annual 1-year required inspection. Administrator, Cynthia Chavez, arrived at 10:00 and LPA explained the purpose of the visit. Administrator certificate 6057158735 expires 9/14/2023. All clients were at the day program.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, garage, and back yard. The facility consists of three (3) 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 73 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 126.7 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Hand washing poster and soap observed at all hand washing stations. 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 was last services on 9/1/2022. Emergency disaster plan last updated 2/4/2023. Fire drill last conducted 10/25/2023. First aid kit was observed to be complete.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2023
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: PHOENIX RESIDENTIAL HOME
FACILITY NUMBER: 079201207
VISIT DATE: 12/07/2023
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Continued from LIC809.

Four (4) staff records were reviewed all are complete. All three (3) clients' records were reviewed, current, and complete. LPAs reviewed P & I.

The following forms to be updated and submitted to CCLD by 10/14/2023:
  • LIC610D Emergency disaster plan (9 pages)
  • LIC500 (Personnel Record)
  • Client Roster
  • LIC308 (Designation of facility Responsibility)
  • Surety bond
  • LIC400 Affidavit Regarding Client/Resident Cash Resources


Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023
LIC809 (FAS) - (06/04)
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