<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440834
Report Date: 03/20/2023
Date Signed: 03/20/2023 12:22:58 PM


Document Has Been Signed on 03/20/2023 12:22 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:ST. REGIS RETIREMENT CENTER, INC.FACILITY NUMBER:
011440834
ADMINISTRATOR:CHINIKAMWALA, SHABBIRFACILITY TYPE:
740
ADDRESS:23950 MISSION BLVD.TELEPHONE:
(510) 881-7888
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY:194CENSUS: 1DATE:
03/20/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Shabbir ChinikamwalaTIME COMPLETED:
12:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 3/20/2023 at 8:45 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct a health and safety inspection and met with Administrator Shabbir Chinikamwala. LPA explained to Shabbir the purpose of the visit.

Administrator informed LPA that there is one resident in the assisted living (R1) and 3 residents in the independent living. Administrator states resident in assisted living is moving out on April 3, 2023. LPA obtained the following records for R1: Physician's Reports for 2016, 2021 and 2022, Admission Agreement, Appraisal Needs and Services Plan, Functional Capability and Preplacement Appraisal.

Administrator states lunch and dinner foods are being provided for free by Bethesda Home. Administrator added that they pick up food for lunch at 11:25 am and dinner at 4:25 pm. In addition to the Administrator, LPA observed two more staff at the facility; Supervisor and Maintenance. At 11:30 am, LPA spoke with Bethesda Home Administrator who confirmed with LPA that they provide foods for 4 residents at the facility.

At 9:50 am, LPA interviewed R1. R1 informed LPA that R1 is moving out of the facility next week.

A copy of this report was provided to Administrator.

SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2023
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 1