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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011400514
Report Date: 04/03/2024
Date Signed: 04/03/2024 05:25:26 PM


Document Has Been Signed on 04/03/2024 05:25 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:PIEDMONT GARDENS #1FACILITY NUMBER:
011400514
ADMINISTRATOR:WITTMAN, DANIELFACILITY TYPE:
741
ADDRESS:110-41ST STREETTELEPHONE:
(510) 654-7172
CITY:OAKLANDSTATE: CAZIP CODE:
94611
CAPACITY:321CENSUS: 63DATE:
04/03/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Zinnia Koch, Director of Wellness and Assisted LivingTIME COMPLETED:
01:35 PM
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On 4/3/2024 at 11:30am, Licensing Program Analyst (LPA) L. Hall conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 2/16/2024. LPA met with Zinnia Koch, Director of Wellness and Assisted Living and explained the purpose of the visit.

S1 submitted a self reported incident for staff misconduct that occurred on 2/14/2024. S1 stated S3 had informed S4 that he witnessed S2 rough handling R1. S2 was suspended pending investigation on 2/14/2024 and returned on 2/19/2024. The facility conducted an internal investigation and found there was no intent to harm R1 and the handling of R1 was misinterpreted. Further interviews from the internal investigation were conducted and there was no complaints. LPA conducted a record review of S3's files and did not observe any previous adverse actions taken. LPA tried to interview R1, but was unsuccessful due to her diagnosis.

LPAs collected the following documents: resident roster, staff roster, and an follow-up incident report dated 2/19/2024

No deficiencies issued during the visit.

Exit interview conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024
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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