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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201223
Report Date: 02/02/2023
Date Signed: 02/02/2023 12:40:38 PM

Document Has Been Signed on 02/02/2023 12:40 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 HOME IIFACILITY NUMBER:
079201223
ADMINISTRATOR:CHAVEZ, CYNTHIAFACILITY TYPE:
735
ADDRESS:57 MAE AVETELEPHONE:
(925) 852-8023
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY: 4CENSUS: 3DATE:
02/02/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Cynthia Chavez, Licensee/AdministratorTIME COMPLETED:
11:50 AM
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On 2/2/2023 at 10:45AM, 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 two (2) bedrooms and one (1) bathroom. 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 115.7 degrees Fahrenheit. Fire extinguisher purchased on 10/5/2022. Facility has locked closet for medications and sharps. There is a minimum of 7-day non-perishables and 2-day perishables foods. Smoke/carbon Monoxide detectors are equipped and operable around the facility. First Aid kit was complete.

Licensing Program Manager (LPM), H. Humpal gave approval to waive Comp III.

Prior to licensure, the following shall be corrected and faxed to CCLD by 02/13/2023.

-LPA observed fence in backyard and patio screen needs repairing.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/02/2023
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 II
FACILITY NUMBER: 079201223
VISIT DATE: 02/02/2023
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Continued from LIC809.

Issues were noted during inspection. LPA observed that facility is not 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: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023
LIC809 (FAS) - (06/04)
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