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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601219
Report Date: 12/17/2024
Date Signed: 12/24/2024 01:52:24 PM

Document Has Been Signed on 12/24/2024 01:52 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:LAKE MERRITT CARE HOMEFACILITY NUMBER:
015601219
ADMINISTRATOR/
DIRECTOR:
IRIS P SERRANOFACILITY TYPE:
740
ADDRESS:576 VALLE VISTA AVENUETELEPHONE:
(510) 832-0442
CITY:OAKLANDSTATE: CAZIP CODE:
94610
CAPACITY: 15TOTAL ENROLLED CHILDREN: 0CENSUS: 14DATE:
12/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Reynaldo Casildo, CaregiverTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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On 12/17/2024 at 9:20 AM, Licensing Program Analysts (LPA) David Doidge arrived unannounced to conduct a annual inspection. Upon entry into the facility, the LPA informed Reynaldo Casildo of the purpose of the visit.

The LPA toured the facility inside and outside. The LPA inspected the kitchen, common areas, bedrooms, bathrooms, and the exterior of the facility. The facility was clean, appropriately furnished, and well lit. More than the 2 days of perishable and 7 days of nonperishable food supplies were available. No body of water was on the facility grounds. Medications are centrally stored. Bathrooms and showers were observed to be fully functioning and clean. The hot water temperature in the bathroom was 109.8 degrees. The room temperature of the living room was 72 degrees. Carbon monoxide and smoke detectors were operational. The fire extinguisher was last serviced on 07/15/2024. Facility has Mitigation Plan, Emergency Disaster Plan, and maintains record of routine screening for residents, staff and visitors.

LPA review five (5) resident records and five (5) staff records. All were complete.

The LPA observed required postings in the facility, Complaint Poster, Ombudsman and Personal Rights posters, and the Theft and Loss Policy. An administrator is on site more than the minimum of 20 hours a week to oversee the proper business operations. Toxins and sharp objects were locked and inaccessible to participants.

Exit interview conducted and a copy of this report provided.
Bennett FongTELEPHONE: (510) 286-4201
David DoidgeTELEPHONE: (916) 475-5913
DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2024
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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