<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601249
Report Date: 09/19/2024
Date Signed: 09/19/2024 03:46:48 PM

Document Has Been Signed on 09/19/2024 03:46 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:RESIDENCES - ANTIOCH, THEFACILITY NUMBER:
075601249
ADMINISTRATOR/
DIRECTOR:		UY JR, FERNANDO NESTOR R.FACILITY TYPE:
740
ADDRESS:5215 HUNSAKER COURTTELEPHONE:
(925) 757-8880
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY: 6CENSUS: 6DATE:
09/19/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:20 PM
MET WITH:Nestor Uy, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:10 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 09/19/24 at 2:20PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced Health and Safety check to discuss hospice waiver requirements.

During the health and safety check, LPA observed a total of 4 staff members and 6 residents at the facility. At 2:40PM, LPA toured facility with administrator, including but not limited to bedrooms, kitchen, bathroom, and common areas. Residents in care appear to be safe and there are no imminent health/safety concerns on today's date.

No deficiencies cited during the health and safety check.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1