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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201223
Report Date: 03/01/2024
Date Signed: 03/01/2024 01:53:58 PM

Document Has Been Signed on 03/01/2024 01:53 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) 267-8879
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY: 4CENSUS: 0DATE:
03/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Cynthia Chavez, AdministratorTIME COMPLETED:
02:05 PM
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On 3/1/2024 at 12:30pm, Licensing Program Analyst (LPA) L. Hall conducted an unannounced annual 1-year required inspection. Administrator Cynthia Chavez, arrived at 1:05pm, and LPA explained the purpose of the visit. The administrator currently holds a certificate (#6057158735) that expires on 9/14/2024. The facility’s fire clearance was approved for four (4) ambulatory clients. Facility does not have any clients at this time.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, garage, and back yard. The facility consists of two (2) total bedrooms and one (1 ) bathroom. All indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 75 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 109.5 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Paper towel, and soap observed at all hand washing stations. The supply of extra hygiene was available for residents.

Smoke detectors/carbon monoxide were in operating condition during visit. Fire extinguisher was last purchased on 10/5/2022. Emergency disaster plan last updated 6/28/2023. Fire drill last conducted 1/13/2024. First aid kit was observed to be complete.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 03/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/01/2024
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 II
FACILITY NUMBER: 079201223
VISIT DATE: 03/01/2024
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Continued from LIC809.

Four (4) staff records were reviewed, and all staff have first aid certification.

The following forms to be updated and submitted to CCLD by 3/8/2024:
  • Surety Bond
  • LIC500 (Personnel Record)
  • LIC308 (Designation of facility Responsibility)
  • LIC400 Affidavit Regarding Client/Resident Cash Resources


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: 03/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2024
LIC809 (FAS) - (06/04)
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