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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201232
Report Date: 03/14/2023
Date Signed: 03/14/2023 11:49:16 AM

Document Has Been Signed on 03/14/2023 11:49 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:ALIVE EAST COUNTYFACILITY NUMBER:
079201232
ADMINISTRATOR:GOLDBERG, ANGELIQUEFACILITY TYPE:
775
ADDRESS:5163 LONE TREE WAYTELEPHONE:
(925) 332-7183
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY: 30CENSUS: 0DATE:
03/14/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Angelique Goldberg, Applicant
Angie Lee, Program Coordinator
Trey Stbible, Health & Safety Coordinator		TIME COMPLETED:
12:00 PM
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On 03/14/23 at 10AM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an announced Pre-licensing visit and met with applicant and 3 staff wearing face masks. LPA explained the purpose of the visit with applicant and staff.

LPA observed facility has two floors. Applicant stated clients will only be using the first floor. The second floor is designated for office use by staff complete with 2 offices, a mixed gender bathroom and full kitchen. LPA observed no clients at the facility. The Fire Safety Clearance Inspection (STD 850) was conducted and granted approval on 11/18/22.

During visit LPA toured the facility which is located inside a commercial building. LPA observed a COVID-19 screening station located at the front entrance for clients, staff and visitors. LPA observed two spacious mixed gender restrooms located in the first and second floors equipped with paper towel holders and covered trash bins. Adjacent to the first floor restroom is a private (Wellness) hygiene/med room with a bed, automated hydraulic lift, cabinet and hygiene supplies for clients. LPA observed toxins will be stored in a locking cabinet in the office upstairs.

LPA observed two designated activities rooms equipped with water stations for clients on the first floor. The kitchen located on the second floor is equipped with a refrigerator and microwave. Two First Aid kits were observed complete. Carbon monoxide detectors were operational. Designated sensory room will be furnished with mood lights, chairs, large pillow, bean bag, music and sensory recreation activities. Emergency disaster plans were observed complete.

Continued on next page, LIC 809-C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2023
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: ALIVE EAST COUNTY
FACILITY NUMBER: 079201232
VISIT DATE: 03/14/2023
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LPA observed a multi-purpose room for clients’ activities and conferences. The program will provide arts and craft, games, music, computers and outside community outings. LPA observed two designated offices for staff with medications stored in locked cabinets. Comfortable temperature was observed at 69 deg F per thermostat reading and 2 fire extinguishers were last inspected on 10/03/22. Hot water temperature tested at 111 deg F. There is a sufficient supply of PPEs and paper products (paper towels and toilet paper).

Component III was waived due to the applicant having sufficient knowledge in operating an Adult Day Program in compliance with Title 22 regulations.

No issues noted during inspection. LPA 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 and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023
LIC809 (FAS) - (06/04)
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