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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011400627
Report Date: 06/01/2022
Date Signed: 06/01/2022 10:38:30 AM


Document Has Been Signed on 06/01/2022 10:38 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:ST. PAUL'S TOWERSFACILITY NUMBER:
011400627
ADMINISTRATOR:YUEN, CONNIEFACILITY TYPE:
741
ADDRESS:100 BAY PLACETELEPHONE:
(510) 835-4700
CITY:OAKLANDSTATE: CAZIP CODE:
94610
CAPACITY:320CENSUS: 191DATE:
06/01/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Connie Yuen, AdministratorTIME COMPLETED:
10:50 AM
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On 06/01/21 at 9:15AM, Licensing Program Analyst (LPA) C. Lin conducted an unannounced case management visit as a result of receiving a self-report death of a resident dated on 05/25/22. LPA explained the purpose of the visit with administrator (ADM).

During the course of interview, LPA obtained a package of documents that subjected resident left when her dead body was found in the apartment on 5/19/2022. The police report and cause of death report were not available at this time. ADM will provide the reports to CCL as soon as possible. ADM stated that the subjected resident was healthy, well being, positive, and independent. There was no knowledge or signs that the subjected resident might suicide.

No deficiency cited during visit. Exit interview conducted with Administrator, and a copy of this report provided.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2022
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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