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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201232
Report Date: 04/09/2024
Date Signed: 04/09/2024 01:28:43 PM

Document Has Been Signed on 04/09/2024 01:28 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:ALIVE EAST COUNTYFACILITY NUMBER:
079201232
ADMINISTRATOR/
DIRECTOR:		GOLDBERG, ANGELIQUEFACILITY TYPE:
775
ADDRESS:5163 LONE TREE WAYTELEPHONE:
(925) 332-7183
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY: 30CENSUS: 7DATE:
04/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Angie Lee, Program Coordinator (PC)
Angelique Goldberg, Administrator		TIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On 04/09/24 at 11AM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced required annual inspection and met with staff (Program Coordinator, S1). LPA explained the purpose of the visit with staff. The Fire Safety Clearance Inspection (STD 850) was conducted and granted approval on 11/18/22.

LPA observed facility has two floors. PC stated the second floor is designated for office use by staff only complete with 2 offices with a mixed gender bathroom and full kitchen.

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, proper hand-washing signs 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. Hot water was observed at 116 deg F. LPA observed toxins stored in a locked cabinet in the front area. Common hallway is equipped with water stations for clients. The partial kitchen located on the first floor is equipped with a refrigerator and microwave. Two first Aid kits were observed complete. Carbon monoxide and smoke detectors were observed operational.

Designated sensory room was observed furnished with mood lights, chairs, large pillow, bean bag, music and sensory recreation activities. Emergency disaster plans were observed complete and posted in a bulletin board on the first floor along with clients' personal rights, Complaint poster, Provider information notices, etc.
Continued on next page, LIC 809-C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/09/2024
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: ALIVE EAST COUNTY
FACILITY NUMBER: 079201232
VISIT DATE: 04/09/2024
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Program provides training regarding independent living skills and social skills. Community outings, activities and exercise sessions are also provided. Toxins, medications and sharps observed stored locked. Staff does not handle client's cash resources. PC is the infection control leader and is on site Monday through Friday (40 hours per week). Fire extinguisher was observed fully charged and last inspected on 10/03/23. Smoke detectors were observed operational. Exits/passageways were observed free of obstruction. LPA reviewed 4 staff and 5 client files during visit.

There were no deficiencies observed/cited during inspection today.



Updated copies of the following documents were obtained from PC:
LIC 308 Designation of Administrative Responsibility
LIC 500 Personnel Report
LIC 610D Emergency Disaster Plan including infection control plans
LIC 9020 Clients' Roster

Exit interview conducted and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024
LIC809 (FAS) - (06/04)
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