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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201246
Report Date: 02/09/2024
Date Signed: 02/09/2024 01:12:32 PM

Document Has Been Signed on 02/09/2024 01:12 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:KUMAR, HARMESHFACILITY TYPE:
735
ADDRESS:4131 SHELTER COVE COURTTELEPHONE:
(925) 826-6557
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY: 6CENSUS: 2DATE:
02/09/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Lu Li, LicenseeTIME COMPLETED:
01:35 PM
NARRATIVE
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On this day at around 11:53 am, Licensing Program Analyst (LPA) Luisa Fontanilla conducted a case management visit related to complaint # 15-AS-20240124094255 and met with Licensee Lu Li.

During the visit, LPA was informed that two more renters who are not fingerprint cleared are staying at the facility and occupying client rooms.

While at the facility, LPA informed Licensee that her request for a waiver to allow renters to live at the facility has been denied by the Department.

Type A deficiency is cited per Title 22 California Code of Regulations (refer to Lic 809D). Failure to submit proof of corrections may result in civil penalties.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2024
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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Document Has Been Signed on 02/09/2024 01:12 PM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Luisa Fontanilla On 02/09/2024 at 12:02 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CONTRA LOMA HOME LLC
FACILITY NUMBER: 079201246

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
02/15/2024
Section Cited
CCR
80019(a)

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Section 80019 (a) Criminal Record Clearance
(a) The Department shall conduct a criminal record review of all individuals specified in Health and Safety Code Section 1522(b) and shall have the authority to approve or deny a facility license, or employment, residence, or presence in the facility, based upon the results of such review.


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The Administrator states she will issue 30-day
eviction notice to the two renters. The Administrator will send LPA a copy of signed notice.
Civil penalty is assessed for today's visit.
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Based on interview conducted, there are two renters at the facility occupying client bedrooms who are not fingerprint cleared.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2024


LIC809 (FAS) - (06/04)
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