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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011400514
Report Date: 08/31/2023
Date Signed: 08/31/2023 12:32:06 PM


Document Has Been Signed on 08/31/2023 12:32 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: 275DATE:
08/31/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Zinnia Koch, Director of WellnessTIME COMPLETED:
01:00 PM
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On this day at around 10 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct a case management visit related to an incident that occurred at the facility. LPA met with Memory Care Manager Laura Roberts and explained the purpose of visit. Director of Wellness Zinnia Koch arrived at the facility and met with LPA at a later time. .

During the visit, LPA interviewed Koch , Roberts, licensed nurse and 8 residents. All residents interviewed state they feel safe living at the facility. And that the staff treat them well.

LPA obtained records for Resident 1 (R1). Koch, Roberts and Nurse all confirmed with LPA that the agency caregiver has been removed from the facility since the incident.

At around 11:25 am, LPA reviewed video footage with Koch and Roberts.

LPA was unable to obtain video footage from the facility. The facility participates in the Safely You program.

The incident will be cross reported to the Home Care Services Bureau (HCSB) for further investigation.

A copy of this report was provided to Roberts.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2023
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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