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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201207
Report Date: 12/03/2024
Date Signed: 12/03/2024 02:46:26 PM

Document Has Been Signed on 12/03/2024 02:46 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/
DIRECTOR:		CHAVEZ, CYNTHIAFACILITY TYPE:
735
ADDRESS:2009 RUBYE DRIVETELEPHONE:
(925) 778-8557
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 4CENSUS: 3DATE:
12/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:25 PM
MET WITH:Cynthia Chavez, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:40 PM
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*Amended to correct LIC809C page*

On 12/3/2024 at 12:25pm, Licensing Program Analyst (LPA) L. Hall conducted an unannounced annual required inspection. LPA met with Administrator, Cynthia Chavez, and explained the purpose of the visit.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, garage, and back yard. The facility consists of three (3) 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 68 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 106.5 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 purchased on 7/22/2024. Emergency disaster plan last updated 6/1/2024. Fire drill last conducted 11/03/2024. First aid kit was observed to be complete.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/03/2024
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: PHOENIX RESIDENTIAL HOME
FACILITY NUMBER: 079201207
VISIT DATE: 12/03/2024
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Continued from LIC809.

Five (5) staff records were reviewed, current, and complete. All three (3) clients' records were reviewed and current.

The following forms to be updated and submitted to CCLD by 12/10/2024:
  • LIC610D Emergency disaster plan (last page)
  • LIC500 (Personnel Record)
  • LIC308 (Designation of facility Responsibility)
  • Surety bond


No deficiencies cited during visit.

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

DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
LIC809 (FAS) - (06/04)
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