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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440776
Report Date: 04/05/2023
Date Signed: 04/05/2023 03:03:06 PM


Document Has Been Signed on 04/05/2023 03:03 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:BAYWOOD COURTFACILITY NUMBER:
011440776
ADMINISTRATOR:MANJOT KAURFACILITY TYPE:
740
ADDRESS:21966 DOLORES STREETTELEPHONE:
(510) 733-2422
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94546
CAPACITY:72CENSUS: 42DATE:
04/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Matthew Neal, President and Nathaniel Runas, Director of Operations.TIME COMPLETED:
03:15 PM
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On 4/5/2023 at 9:45AM, Licensing Program Analysts (LPAs) L. Hall and L.Fici conducted an unannounced 1-Year Required inspection. LPAs met with Matthew Neal, President and Nathaniel Runas, Director of Operations. and explained the purpose of the visit. Administrator, Manjot Kaur, arrived at 10:55am. The Administrator currently holds a certificate (#6062932740) that expires on 10/12/2024. The facility’s fire clearance was approved for seventy-two (72) non-ambulatory residents.

LPAs toured the facility with Director of Operations including but not limited to bedrooms, bathrooms, kitchen, common areas. All outdoor and indoor passageways are kept free of obstruction. LPAs did not observe any bodies of water. A comfortable temperature is maintained at 72 degrees Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom in the common area was measured at 105.5 degrees Fahrenheit. Hot water temperature in resident's room was measured at 101.8 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods.

Facility has a fire system. Fire extinguisher was last serviced on 04/01/2023. Emergency Disaster Plan was last posted on 10/10/2022. First aid kit was observed to be complete. Fire drill was last conducted on 03/20/2023 and 3/21/2023..

Continued on LIC809.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: BAYWOOD COURT
FACILITY NUMBER: 011440776
VISIT DATE: 04/05/2023
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Continued from LIC809.

Five (5) staff records were reviewed, and all staff have criminal record clearance and hold a current first aid certificate. LPAs also reviewed five (5) resident records and a sample of residents' medication.

LPA requested the following documents to be submitted to CCLD by 04/12/2023.

LIC 610E Emergency Disaster Plan
Liability Insurance

No deficiencies cited during visit.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2