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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201367
Report Date: 05/22/2024
Date Signed: 05/22/2024 03:08:26 PM

Document Has Been Signed on 05/22/2024 03:08 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:DLC ELDERLYFACILITY NUMBER:
079201367
ADMINISTRATOR/
DIRECTOR:		DE LA CRUZ, WILFREDFACILITY TYPE:
740
ADDRESS:5501 PINNACLE VIEW WAYTELEPHONE:
(925) 787-4431
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY: 6CENSUS: 0DATE:
05/22/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Wilfred De La Cruz, Administrator/ApplicantTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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On 05/22/24 at 1PM. Licensing Program Analyst (LPA) Daisy Panlilio arrived announced to conduct a pre-licensing inspection. LPA met with Administrator (ADM) and explained the purpose of the visit. The facility currently has no residents. ADM has a current administrator certificate # 6050190740 which expires 09/22/24.

LPA toured the facility with ADM including but not limited to the residents' bedrooms, common areas, kitchen, and outdoor area. LPA observed a screening station near the front entrance with a no touch temperature probe, visitors' log and hand sanitizer. Facility has adequate lighting. Indoor and outdoor passageways were observed free of obstruction. There were no bodies of water observed. LPA advised ADM that hot water temperature should be maintained between 105 degrees F and 120 degrees F. LPA observed 2 days supply of perishable and one week supply of non-perishable foods. Towels, sheets, activity supplies and hygiene products were observed available. The facility has 2 full bathrooms. LPA observed the shower area has non-skid floor mats. There are activity materials observed in the living room/office. Facility has flashlights available for emergency use. LPA observed sufficient emergency supplies stored inside the garage. There is sufficient lighting throughout facility. First-aid kit was observed to be complete. Smoke detectors and carbon monoxide were operational. Fire extinguisher was observed fully charged and purchased on 03/26/24. Proper hand-washing signs, Emergency/Disaster plans/contact information, personal rights were observed posted in common areas.

LPA observed no deficiencies during inspection. LPA observed that facility is ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAU. Additional requirements may still be required.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/22/2024
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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