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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011400514
Report Date: 10/14/2022
Date Signed: 10/14/2022 02:46:03 PM


Document Has Been Signed on 10/14/2022 02:46 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:PIEDMONT GARDENS #1FACILITY NUMBER:
011400514
ADMINISTRATOR:WITTMAN, DANIELFACILITY TYPE:
741
ADDRESS:110-41ST STREETTELEPHONE:
(510) 654-7172
CITY:OAKLANDSTATE: CAZIP CODE:
94611
CAPACITY:321CENSUS: 268DATE:
10/14/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Daniel Wittman, AdministratorTIME COMPLETED:
02:55 PM
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On 10/14/22 at 2:00PM, Licensing Program Analyst (LPA) C. Lin conducted an unannounced case management visit as a result of receiving residents from Grand Lake Gardens due to evacuation from major fire. LPA met with Administrator and explained the purpose of the visit.

LPA observed that Piedmont Gardens opened 2 dining halls to accommodate residents from Grand Lake Gardens. Residents were safe and chatting in the dining rooms. Staff were assisting residents for getting clothing, refiling medications, and contacting their families. Administrator stated that most of residents from Grand Lake Gardens would be placed in hotel(s) in Emeryville except a few of them who require medication assistance might stay in Piedmont Garden.

Food, paper, PPE, and other supples are adequate. Staffing is stable.

Exit interview conducted with Administrator and copy of this report provided.
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)
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