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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011400514
Report Date: 10/28/2022
Date Signed: 10/28/2022 11:06:51 AM


Document Has Been Signed on 10/28/2022 11:06 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:PIEDMONT GARDENS #1FACILITY NUMBER:
011400514
ADMINISTRATOR:WITTMAN, DANIELFACILITY TYPE:
741
ADDRESS:110-41ST STREETTELEPHONE:
(510) 654-7172
CITY:OAKLANDSTATE: CAZIP CODE:
94611
CAPACITY:321CENSUS: 260DATE:
10/28/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Zinnia Koch, Wellness DirectorTIME COMPLETED:
11:15 AM
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On 10/28/22 at 9:20AM, Licensing Program Analysts (LPAs) C. Lin conducted an unannounced case management visit as a result of receiving residents from Grand Lake Gardens (GLG) and check on residents. LPA met with Wellness Director and explained the purpose of the visit.

During visit, LPA obtained GLG resident's roster and Piedmont Gardens (PG) staff schedules. Total of 32 residents from GLG had moved in to PG including 3 of them admitted to PG prior to the fire. LPA interviewed 5 residents who stated that they were happy living at PG, they were fed well and needs were met.

Some GLG staff were transferred to PG to work so staffing is stable. Adequate food, paper, PPE supplies were observed.

There was no imminent health/safety concerns on today's date.

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: 10/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2022
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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