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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011400514
Report Date: 10/17/2022
Date Signed: 10/17/2022 03:40:58 PM


Document Has Been Signed on 10/17/2022 03:40 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: 236DATE:
10/17/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Zinnia Koch, Wellness DirectorTIME COMPLETED:
03:50 PM
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On 10/14/22 at 2:00PM, Licensing Program Analysts (LPAs) C. Lin and L. Francisco conducted an unannounced case management visit as a result of receiving residents from Grand Lake Gardens due to evacuation from major fire. LPAs met with Wellness Director and explained the purpose of the visit.

During visit, LPAs obtained resident's roster from Piedmont Gardens (PG) and Grand Lake Gardens (GLG) with contact information, staff schedules, LPAs observed that 20 residents from GLG were admitted to (PG) from 10/14/22 to 10/16/22. Out of 20 residents, one resident was discharged from hospital and admitted to Skill Nursing on 10/16/22, one of them was admitted to Assisted Living on 10/14/22, and 18 of them were admitted to Independent Living on either 10/14/22 or 10/15/22.

The Administrator from GLG, Scott Mueller arrived at PG at 2:30pm and provided updates to GLG residents. GLG resident roster indicated that 20 other residents stayed in Hyatt House in Emeryville, the rest of 43 residents stayed at home with family member. LPAs were advised that it would take at least 3 months to reopen GLG.

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

Exit interview conducted with Wellness Director 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: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2022
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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