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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201282
Report Date: 11/01/2023
Date Signed: 11/01/2023 12:31:04 PM

Document Has Been Signed on 11/01/2023 12:31 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:BUENAVISTA CARE @ BUTTERCUPFACILITY NUMBER:
079201282
ADMINISTRATOR:PEREZ, ROBERTOFACILITY TYPE:
735
ADDRESS:2814 BUTTERCUP CTTELEPHONE:
(925) 917-9640
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY: 4CENSUS: 0DATE:
11/01/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Roberto Perez, ApplicantTIME COMPLETED:
12:45 PM
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On 11/01/23 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 03/21/23 for 4 residents. There are 4 bedrooms and 2 bathrooms. Posters including but not limited to Covid-19 related posters, complaint poster, Personal Rights were observed. 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. Plates, silver wares and glass wares were observed available. A copy of menu was posted on the refrigerator. Hot water measured at 119 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 laundry room. LPA observed chairs and tables in the backyard with a covered porch for use of clients. There were no bodies of water observed.

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 via email.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2023
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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