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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011400514
Report Date: 11/09/2022
Date Signed: 11/09/2022 03:37:56 PM


Document Has Been Signed on 11/09/2022 03:37 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: 265DATE:
11/09/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Zinnia Koch, Wellness DirectorTIME COMPLETED:
03:45 PM
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On 11/9/22 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 (GLG) and check on residents. LPA met with Wellness Director and explained the purpose of the visit.

A total of 35 residents from GLG are currently living in PG. During visit, LPA met with 6 residents. 1 resident brought up a concern of resident's mental health after the fire incident, LPA discussed it with Wellness Director who stated that she would follow up. Other than that, residents stated that they were feeling safe, fed well, and their needs were met.

Supplies were adequate and staffing is stable.

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: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2022
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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