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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803965
Report Date: 05/25/2023
Date Signed: 05/25/2023 04:21:39 PM

Document Has Been Signed on 05/25/2023 04:21 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
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: 4DATE:
05/25/2023
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Mark Oribello, LicenseeTIME COMPLETED:
04:21 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct an Annual Required 1 Year inspection and met with care staff, Danilo Salcedo, Administrator Mark Oribello arrived a few minutes later. This facility is licensed for 4 ambulatory clients.

LPA toured facility and observed: Facility is a one floor residence, with a total of 5 bedrooms, 3 baths, living room, dinning room, kitchen, activity room and laundry room. The master bedroom and bathroom is used for live-in staff, and room was observed locked. The other 4 bedrooms, 2 baths are used by clients. The facility was observed to be clean, very well organized, in good repair, with all exits free from obstruction. All bedrooms were observed to have the required furnishings, such as a bed, night stand, dresser, lamp and a chair. Beds were observed to have the required linens. Hallways were observed with automatic night-lights for the safety of the clients. There is an ample supply of personal hygiene products, extra bedding, towels and linens. The refrigerator was observed to be clean and there was plenty of perishable and Non perishable foods that appeared to be in good condition. A designated locked cabinet in the kitchen stores knives and sharps. The cabinet under the kitchen sink and the cabinet in the laundry room are used to store cleaning supplies and LPA observed them locked with magnet lock. The facility has a first aid kit available. Personnel records and clients records are stored in locked cabinet. LPA reviewed all 4 client files and 3 staff files. Medications are kept locked and inaccessible to clients.

Report continued on LIC 809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 05/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/25/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ANTIQUITY HOME, LLC
FACILITY NUMBER: 486803965
VISIT DATE: 05/25/2023
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This facility has built in ceiling fire sprinklers, a working carbon monoxide detector and smoke alarms that were operational at the time of inspection. There were 2 fire extinguishers that were charged and serviced on 6/2/2022. Water temperature tested at 105 degrees f. and within the required 105-120 degrees f.

This facility has a granny unit separate from the home, with their own entrance. Licensee and staff explained the granny unit is used for staff. Facility understands anyone living in the granny unit will need to be fingerprinted and cleared prior to being present or living in the unit.
LPA consulted regarding getting clarification on client C1s ambulatory status as their Physician report goes back and forth regarding this matter.


Licensee/Administrator to submit updates of the following documents by 6/20/2023.

· Copy of Administrator Certificate
· LIC 308 Designation of Facility Responsibility
· LIC 500 Personnel Report
· LIC 400 Affidavit Regarding Client/Resident Cash Resources
· LIC 402 Surety Bond (If applicable)
· LIC 610D Emergency Disaster Plan
· LIC 9020 Register of Facility Clients
· Copy of current Lease/Rental Agreement or Property Tax document showing control of property.

· Infection Control Plan of Operation (If changes)



No deficiencies cited during today's visit. Exit interview conducted with Mark Oribello.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023
LIC809 (FAS) - (06/04)
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