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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803965
Report Date: 09/02/2021
Date Signed: 09/02/2021 01:31:16 PM

Document Has Been Signed on 09/02/2021 01:31 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:ANTIQUITY HOME, LLCFACILITY NUMBER:
486803965
ADMINISTRATOR:ORIBELLO, MARK & GRACEFACILITY TYPE:
735
ADDRESS:904 ANTIQUITY DRIVETELEPHONE:
(408) 313-0173
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY: 4CENSUS: 3DATE:
09/02/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:16 AM
MET WITH:Mark and Grace Oribello, AdministratorsTIME COMPLETED:
01:45 PM
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 Licensing Program Analyst (LPA) Lopez conducted an unannounced case management inspection and met with Administrators, Mark and Grace Oribello. The purpose of the case management inspection was to follow up on self reported incident report submitted to Community Care Licensing (CCL) that occurred on 8/23/21.

On 8/23/21, facility reported C1 was aggressive towards S1. Facility is monitoring client and finding ways to help R1's behavior. Facility has been in contact with psychiatrist about C1's behavior and have conducted interviews with staff about C1. During visit LPA Lopez requested documents and took statements from staff and Administrators.

No deficiencies cited during this inspection
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Karen Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/02/2021
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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