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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011400246
Report Date: 04/19/2023
Date Signed: 04/19/2023 10:25:58 AM


Document Has Been Signed on 04/19/2023 10:25 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
CCLD Regional Office, 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:
04/19/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Scott Mueller,Administrator TIME COMPLETED:
10:30 AM
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On 4/19/2023, at 10:00 AM, Licensing Program Analysts (LPA) L. Fici arrived to conduct a facility closure inspection. LPA met and was greeted by Scott Mueller, Administrator (ADM), and explained the purpose of the visit.

LPA toured entire facility with Licensee including kitchen, bathrooms, bedrooms, and common areas. LPA confirmed that all residents are moved out. All residents moved out October 14,2022.

Licensee surrendered their license by mailing it to CCL. A forfeiture letter will be mailed to licensee at a later time.

No deficiencies cited during visit.

Exit interview conducted with ADM and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon FiciTELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2023
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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