079200752-2-7-2025-15-AS-DPAO-DDP2B4-20250207161431

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200752
Report Date: 02/07/2025
Date Signed: 02/07/2025 04:14:42 PM

Document Has Been Signed on 02/07/2025 04:14 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:	FERNBANK PLACE LLC		FACILITY NUMBER:	079200752
ADMINISTRATOR/ DIRECTOR:	IAN SALALILA		FACILITY TYPE:	740
ADDRESS:	5035 FERNBANK WAY		TELEPHONE:	(925) 732-7418
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94531
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	02/07/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	03:10 PM
MET WITH:	Ian Salalila, Administrator Alma Alcantara, Staff		TIME VISIT/ INSPECTION COMPLETED:	05:30 PM

NARRATIVE

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On 02/07/25 at 3:10PM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct an annual required inspection. LPA met with administrator (ADM) and explained the purpose of the visit. LPA observed administrator certificate # 6002333740 is current with expiration date of 04/10/2025.

At 3:30PM, LPA toured the facility including but not limited to the front entrance, screening station, kitchen, bathrooms, bedrooms and common areas. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, visitor’s logs, no touch thermometer, additional face masks and hand sanitizers were observed at the screening station. Emergency Disaster Plan, Complaint poster, Personal rights, Cough/sneeze etiquette, proper hand-washing signs were observed posted in common areas. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Facility has a 30-day supply of PPEs, paper, medications locked in cabinets. Comfortable temperature is maintained at 74 deg F.
Facility has a mitigation plan in place and the infection control leader is the administrator. Inside and outside pathways were free of obstruction and fire hazards. Smoke and Carbon monoxide detectors were operational. LPA observed fire extinguisher fully charged and last inspected on 05/04/24. LPA reviewed 4 staff and 5 resident files.

The following deficiency was observed during visit:

Hot water temperature measured at 147.2 deg F

Continued on next page, LIC 809-C

Bennett Fong	TELEPHONE: (510) 622-2621
Daisy Panlilio	TELEPHONE: (510) 286-4201
	DATE: 02/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2025

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: FERNBANK PLACE LLC	FACILITY NUMBER: 079200752
	VISIT DATE: 02/07/2025

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Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Updated copies of the following documents were collected for facility file:

 LIC500- Personnel Report
 Residents Roster
 LIC308- Designation of Facility Responsibility
 LIC610E- Emergency/Disaster Plan including infection control plans
 Evidence of Liability Insurance

Exit interview conducted, Appeal Rights and a copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/07/2025 04:14 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: FERNBANK PLACE LLC	FACILITY NUMBER: 079200752
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87303(e)(3)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/21/2025
	Plan of Correction
1 2 3 4	By POC due date, Administrator agrees to adjust hot water temperature and submit a photo of hot water temperature within the compliant range of minimum 105 deg F to 120 deg F.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Bennett Fong	TELEPHONE: (510) 622-2621
Daisy Panlilio	TELEPHONE: (510) 286-4201
	DATE: 02/07/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2025

LIC809 (FAS) - (06/04)

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