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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440834
Report Date: 04/19/2023
Date Signed: 04/19/2023 01:23:41 PM


Document Has Been Signed on 04/19/2023 01:23 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: 0DATE:
04/19/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Shabbir ChinikamwalaTIME COMPLETED:
01:50 PM
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At around 1:00 PM, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct case management facility closure visit and met with Shabbir Chinikamwala.

LPA and Shabbir did the final walk through in the assisted living and Memory Care unit. The last resident in the assisted living moved out of the facility on April 6, 2023. There were no residents in the AL and Memory Care unit observed during the visit.

Administrator surrendered facility license to LPA.

Exit interview was conducted and a copy of this report was provided to Shabbir.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2023
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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