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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600526
Report Date: 10/19/2021
Date Signed: 10/19/2021 04:31:10 PM

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:ELDERS INN ON WEBSTERFACILITY NUMBER:
015600526
ADMINISTRATOR:MARIE ANN LAGASCAFACILITY TYPE:
740
ADDRESS:1721 WEBSTER STREETTELEPHONE:
(510) 521-9200
CITY:ALAMEDASTATE: CAZIP CODE:
94501
CAPACITY:60CENSUS: 31DATE:
10/19/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Stephen ZimmermanTIME COMPLETED:
03:15 PM
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On 10/19/2021 starting at 2:20 PM, Licensing Program Analyst (LPA) L. Ibo conducted a health and safety check as a result of department receiving a priority 1 complaint. LPA met with nurse Remy Todd and Administrator Stephen Zimmerman.

During the health and safety check, LPA toured the building with Administrator Stephen Zimmerman including but not limited to common areas, bathrooms, bedrooms and outdoor area. LPA observed smoke detectors and carbon monoxide detector throughout facility.

Residents in care appear to be safe and there are no imminent health/safety concerns on today's date. Facility is maintained at a comfortable temperature for the clients in care.

No deficiencies were cited today.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021
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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