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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201246
Report Date: 07/07/2023
Date Signed: 07/07/2023 12:34:32 PM

Document Has Been Signed on 07/07/2023 12:34 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:CONTRA LOMA HOME LLCFACILITY NUMBER:
079201246
ADMINISTRATOR:LI, LUFACILITY TYPE:
735
ADDRESS:4131 SHELTER COVE COURTTELEPHONE:
(925) 826-6557
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY: 6CENSUS: 0DATE:
07/07/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Lu Li, ApplicantTIME COMPLETED:
11:15 AM
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 07/07/23 at 10AM, Licensing Program Analyst (LPA) Daisy Panlilio conducted a scheduled visit to this facility for the purpose of completing a Pre-licensing evaluation. LPA met with Applicant Lu Li and explained the purpose of the visit.

LPA toured the facility indoors and outdoors. The facility is a 5 bedroom 3 bathroom two story house. All 5 bedrooms are designated for clients, one of which is a shared bedroom with an adjacent bathroom. There is one common bathroom located near the 2 private bedrooms (B3 and B4). The fire extinguisher was located in the dining area adjacent to the kitchen. Smoke detectors are hardwired throughout the main floor and are equipped with carbon monoxide detection. All were tested and operational.

Continued on next page, LIC 809-C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2023
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 2
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: CONTRA LOMA HOME LLC
FACILITY NUMBER: 079201246
VISIT DATE: 07/07/2023
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
26
27
28
29
30
31
32
Beds were made with appropriate linens and additional linens were observed to be on hand in a linen cabinet located in the second story hallway. Furniture and lighting were observed to be safe and adequate. Each bedroom was furnished with a bed, bedding, a night stand, a chair, and sufficient closet space. Hot water temperature in the resident bathrooms tested at 111 degrees Fahrenheit. There were no bodies of water present at the facility. Outside pathways to security exit gate were unobstructed.

As this is a new facility, clients were not present during today’s visit. During today's visit, LPA reviewed LIC 610E Emergency disaster plan/Fire and Earthquake drill requirements. A fire clearance for this facility was granted on 01/27/23 for a capacity of 6 ambulatory clients.

LPA observed that facility is ready to be licensed. This report will be submitted to the Central Applications Branch (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB.
Additional requirements may still be required.

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

DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2