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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201256
Report Date: 04/20/2023
Date Signed: 04/20/2023 11:27:30 AM


Document Has Been Signed on 04/20/2023 11:27 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:A LOVING HOMEFACILITY NUMBER:
079201256
ADMINISTRATOR:ALOOT, DONNIEFACILITY TYPE:
740
ADDRESS:3420 CLAYBURN RD.TELEPHONE:
(951) 522-1228
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:6CENSUS: 0DATE:
04/20/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Donnie Aloot, ApplicantTIME COMPLETED:
12:00 PM
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At 10AM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced pre-licensing visit and met with applicant. LPA explained the purpose of the visit with applicant.

Facility has an approved fire clearance dated 03/08/23 for 6 residents. There are 3 bedrooms and 2 bathrooms. Emergency Disaster Plan and posters such as complaint poster and Personal Rights were observed displayed in common areas. All bedrooms were observed furnished with a bed, dresser, closet, night stand, lamp and chair. Hallways and passageways were free of obstruction. There was sufficient lighting and furniture. The kitchen was observed clean and organized. There was sufficient supply of non-perishable foods observed. Hot water measured at 109 deg F. There was a locked cabinet for medicine and resident files. Knives and other sharp objects and chemicals were kept in a locked drawer and cabinets in the kitchen & garage. There was sufficient supply of towels, sheets, blankets and hygiene products observed. Smoke detector and carbon monoxide were tested and observed operational. First aid kit was complete. There were activity materials available. Facility has a washer and dryer installed in the garage. LPA observed chairs and table in the backyard with a covered porch for use of residents. There were no bodies of water observed.

No deficiencies observed during visit. 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 provided to applicant.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 04/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2023
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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