<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201231
Report Date: 01/31/2024
Date Signed: 01/31/2024 01:00:56 PM

Document Has Been Signed on 01/31/2024 01:00 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: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: 1DATE:
01/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Dayana Coulter, AdministratorTIME COMPLETED:
01:35 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 01/31/24 at 12:10PM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct an annual required inspection. LPA met with administrator (ADM) and explained the purpose of the visit.

LPA toured the facility including but not limited to the front entrance, screening station, kitchen, bathrooms, bedrooms and common areas. There is one central entry point for universal screening for staff, clients and visitors. A sign-in policy, visitor’s logs, no touch thermometer, additional face masks and hand sanitizers were observed at the screening station. Emergency Disaster Plan, Complaint poster, Personal rights, Cough/sneeze etiquette, proper hand-washing signs were observed posted in common areas. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Facility has a 30-day supply of PPEs, paper, medications locked in cabinets. Comfortable temperature is maintained at 68 deg F. Hot water temperature was measured at 107 deg F. Facility has a mitigation plan in place and the infection control leader is the administrator. Inside and outside pathways were free of obstruction and fire hazards. Smoke and Carbon
monoxide detectors were operational. Fire extinguishers were observed fully charged and last inspected on 09/0
7/23. LPA reviewed 3 staff and 1 client files. LPA also conducted 2 staff and 1 client interviews during visit.

Updated copies of the following documents were collected for facility file:
 LIC500- Personnel Report
 Clients Roster
 LIC308- Designation of Facility Responsibility
 LIC610D- Emergency/Disaster Plan including infection control plans
 Evidence of Surety Bond
No deficiencies observed during visit. Exit interview conducted and a copy of the report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1