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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201231
Report Date: 01/27/2023
Date Signed: 01/27/2023 10:51:18 AM

Document Has Been Signed on 01/27/2023 10:51 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:DC CARE HOME #2FACILITY NUMBER:
079201231
ADMINISTRATOR:COULTER, DANIEL T.FACILITY TYPE:
735
ADDRESS:4915 TIMBERBROOK WAYTELEPHONE:
(925) 207-7522
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY: 3CENSUS: 0DATE:
01/27/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Daniel Coulter, Licensee and Dayana Coulter, AdministratorTIME COMPLETED:
10:55 AM
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On 01/27/2023 at 10:00AM, Licensing Program Analyst (LPA) L. Hall conducted an announced pre-licensing inspection. LPA met with Daniel Coulter, Licensee and Dayana Coulter, Administrator. The facility has an approved fire safety clearance for three (3) 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 one-half (2 1/2) bathrooms. There were no bodies of water present during inspection. There is sufficient lighting around the facility. Clients rooms are equipped with the proper furniture, bedding, and lighting. Bathrooms showers/tubs were equipped with non skid mats. Passageways and hallways are free of obstruction. Locked closet available to store medications, toxins and sharps. Hot water temperature is measured at 108.5 degrees Fahrenheit. Fire extinguisher was purchased November 2022. There is a minimum of 7-day non-perishables and 2-day perishables foods. First Aid kit was complete. Carbon monoxide and smoke detectors present.

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

No issues were noted during inspection. LPAs 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 with Administrator and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2023
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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