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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011400246
Report Date: 01/31/2023
Date Signed: 01/31/2023 09:49:02 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/31/2023 09:49 AM - 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:
01/31/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Scott Mueller, Director of Resident ServicesTIME COMPLETED:
09:55 AM
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On 1/31/2023 starting at 9:20 a.m., Licensing Program Analyst (LPA) Catherine Lin arrived unannounced to conduct Infection Control Inspection. LPA met with the Director of Resident Services, Scott Mueller and disclosed the purpose of the visit.

There was no resident living at the facility due to the fire damage last year. Residents' room were empty, residents' furniture were located in the garage. A few administrative and maintenance team members were still working in the facility for coordinating moving furniture. LPA was confirmed that facility will be permanently closed in March 2023.

Exit interview conducted and copy of this report is provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2023
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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