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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201406
Report Date: 01/15/2025
Date Signed: 01/15/2025 02:06:39 PM

Document Has Been Signed on 01/15/2025 02:06 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:LIBERTY RESIDENTIAL CARE HOMEFACILITY NUMBER:
079201406
ADMINISTRATOR/
DIRECTOR:		HENRY, CARLAFACILITY TYPE:
735
ADDRESS:3017 ALDRICH STREETTELEPHONE:
(510) 830-6068
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY: 4CENSUS: 0DATE:
01/15/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Carla Henry, ApplicantTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On 01/15/25 at 12PM. Licensing Program Analyst (LPA) Daisy Panlilio arrived announced to conduct a pre-licensing inspection. LPA met with applicant/Administrator (ADM) and explained the purpose of the visit. The facility currently has no clients. ADM has a current Adult Residential Facility (ARF) certificate # 6047572735 which expires 12/25/2026.

At 1PM, LPA toured the facility with ADM including but not limited to the clients' bedrooms, common areas, kitchen, and outdoor area. LPA observed a screening station near the front entrance with a no touch temperature probe, visitors' log and hand sanitizer. There is sufficient lighting throughout facility. Indoor and outdoor passageways were observed free of obstruction. There were no bodies of water observed. LPA advised ADM that hot water temperature should be maintained between 105 degrees F and 120 degrees F. LPA observed 2 days supply of perishable and one week supply of non-perishable foods. Towels, sheets, activity supplies and hygiene products were observed available. The facility has 3 full bathrooms. LPA observed the shower area has non-skid floor tiles. There are activity materials observed in the living room. Facility has flashlights available for emergency use. The facility has an attached garage that will be used as storage space for tools and extra emergency supplies. First-aid kit was observed to be complete. Smoke detectors and carbon monoxide were operational. Fire extinguisher was observed fully charged. Proper hand-washing signs, Emergency/Disaster plans/contact information, personal rights were observed posted in common areas.

LPA observed no deficiencies during inspection. LPA observed that facility is ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAU. Additional requirements may still be required.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/15/2025
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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