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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011400246
Report Date: 10/14/2022
Date Signed: 10/14/2022 01:46:04 PM


Document Has Been Signed on 10/14/2022 01:46 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:GRAND LAKE GARDENSFACILITY NUMBER:
011400246
ADMINISTRATOR:BRANDMEIER, PHILIPFACILITY TYPE:
741
ADDRESS:401 SANTA CLARA AVENUETELEPHONE:
(510) 893-8897
CITY:OAKLANDSTATE: CAZIP CODE:
94610
CAPACITY:135CENSUS: 0DATE:
10/14/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Staff is not availableTIME COMPLETED:
01:50 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 10/14/22 at 12:25PM, Licensing Program Analyst (LPA) C. Lin conducted an unannounced case management visit as a result of receiving a news regarding facility fire occurred at approximately 6:00am this morning. Upon arrival, LPA observed no resident and staff were at the premises.

LPA spoke with Administrator Scott Mueller on the phone and obtained the following information. Administrator stated that 83 residents in the building were evacuated. All residents were independent living. There was no memory care and assisted living residents in the facility. 2 residents were sent to ER at Summit and Kaiser hospital, One of them has been released and picked up by family member, another one is still in Kaiser but will be released soon today. About 8 residents were picked up by family member and choose to stay with family. Other residents were temporarily transported to Piedmont Gardens for lunch. Administrator is in the process of residents' placement. Administrator stated that resident would either stay with family members, in Piedmont Gardens, or in contracted hotels in Emeryville where there were 46 vacant rooms currently.

Administrator stated that the fire started in a resident's room on the 5th floor, cause of fire was unknown at the moment. Administrator stated that it would take a while for residents returning to facility because of fire and water damage of the building. More accurate information and updates are forthcoming.

LPA requested the relocation plan from Administrator on the phone to be provided to CCL ASAP, and discussed the report with Administrator on the phone.

No signature is available during visit.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2022
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