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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 02:06:04 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:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:38 PM
MET WITH:Carla Henry, Applicant/AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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On 01/15/25 at 1:38PM, while at the facility for another reason, Licensing Program Analyst (LPA) D Panlilio conducted a component III presentation with administrator (ADM)/ applicant.

LPA discussed the common deficiencies that adult residential facilities are cited on, Title 22 regulations on infection control, physical plant, personnel requirements on clearances and associations, training, emergency/disaster/food requirements, etc. ADM agrees to be in substantial compliance with Title 22 regulations.

ADM was reminded of the statute that requires CCL to be notified within 5 business days of admitting their first client. This notification may be done by phone, by mail, or by fax.

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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