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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201044
Report Date: 03/04/2025
Date Signed: 03/04/2025 05:18:08 PM

Document Has Been Signed on 03/04/2025 05:18 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:DEER RIDGE COUNTRY VILLAFACILITY NUMBER:
079201044
ADMINISTRATOR/
DIRECTOR:		SALAZAR, HENRYFACILITY TYPE:
740
ADDRESS:419 DEL MONTE COURTTELEPHONE:
(925) 997-7354
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 6CENSUS: 4DATE:
03/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Kimberlet Whittle, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
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On 03/04/2025 at 2:30PM, Licensing Program Analyst (LPA) T. Syess-Gibson, arrived unannounced to continue the 1-Year Annual Required inspection visit. LPA met with Administrator, Kimberly Whittle and explained the purpose of the visit. Administrator certificate #6067792740 expires 10/11/2025. The facility’s fire clearance was approved for Six (6) Non-ambulatory residents. Facility has hospice waiver for Three (3) residents.


LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area, garage, and backyard. All outdoor and indoor passageways are kept free of obstruction. LPA did not observe any bodies of water. A comfortable temperature is maintained at 72 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 116.5 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-slip shower mats. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 07/02/2024. First aid kit was observed to be complete. Fire and Disaster drills conducted quarterly.

Continued on LIC809C...
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2025
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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: DEER RIDGE COUNTRY VILLA
FACILITY NUMBER: 079201044
VISIT DATE: 03/04/2025
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Continued from LIC809.

Four (4) staff records were reviewed, all staff records were complete. LPA reviewed four (4) resident records, and they were current and complete.

LPA requested the following documents to be submitted to CCLD by 03/11/2025.

· LIC 308 Designation of Administrative Responsibility
· LIC 309 Administrative Organization
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan (last page)
· Liability Insurance

No deficiencies cited during visit.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025
LIC809 (FAS) - (06/04)
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