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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601373
Report Date: 09/08/2022
Date Signed: 09/08/2022 03:02:48 PM

Document Has Been Signed on 09/08/2022 03:02 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:SHEILA'S CRYSTAL CARE HOME IIIFACILITY NUMBER:
075601373
ADMINISTRATOR:GARCIA, BIENVENIDO & LUZFACILITY TYPE:
740
ADDRESS:1649 OBSERVATION COURTTELEPHONE:
(925) 755-9513
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY: 6CENSUS: 4DATE:
09/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:18 PM
MET WITH:Bienvenido Garcia, AdministratorTIME COMPLETED:
03:20 PM
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On 09/08/2022 at 2:18PM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct infection control inspection. LPA met with administrator and explained the purpose of the visit. Facility staff were observed wearing face masks during visit.

LPA toured the facility including but not limited to common areas, kitchen, bedroom, and shared bathrooms. to front entrance, screening station, hand washing stations, 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 sanitizer were observed at the screening station. Cough/sneeze etiquette, social distancing signs were 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 medications and PPE stored at a locked cabinet near the living room. Facility has mitigation/infection control plans and maintains records of routine screening for residents and staff. Pathways inside and outside were observed free of fire hazards and obstruction.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 09/09/22:
· LIC500- Personnel Report
· LIC308- Designation of Facility Responsibility
· LIC610E- Emergency/Disaster Plan with Infection Control Plans
· Evidence of Liability Insurance

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2022
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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