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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601284
Report Date: 05/10/2022
Date Signed: 05/10/2022 12:17:33 PM


Document Has Been Signed on 05/10/2022 12:17 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:RAKSHA 6FACILITY NUMBER:
015601284
ADMINISTRATOR:BHUTANI, NALANIFACILITY TYPE:
740
ADDRESS:1133 GARFIELD AVENUETELEPHONE:
(510) 558-7241
CITY:ALBANYSTATE: CAZIP CODE:
94706
CAPACITY:6CENSUS: 0DATE:
05/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Administrator, Nalini Bhutani (ADM) TIME COMPLETED:
12:36 PM
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On 05/10/2022 at 11:37 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct an Infection Control Inspection, LPA was greeted by the Administrator, Nalini Bhutani (ADM). The facility does not have any residents at this time.

Facility has a COVID-19 mitigation plan on file. LPA requested a staff and resident roster from ADM once residency begins. LPA observed screening station at the entry with hand sanitizer. ADM has painted and completed some upgrades to the floors, kitchen and bathrooms. ADM will create an isolation cart and maintain a 30-day supply of PPE. LPA toured the facility including, but not limited to common areas, bathrooms, bedrooms, kitchen, and patio. ADM to post COVID-19, cough etiquette, masks, social distancing and hand washing signs throughout. There is a locked cabinet for medication, locked drawer for sharps and locked closet for disinfectants. Hand washing stations and bathrooms are to be equipped with soap, paper towels, and covered garbage cans. Hot water temperature in the shared residents' bathroom was measured at 117.2 degrees Fahrenheit (F). Fire extinguisher last inspected 01/04/2022. Smoke/Carbon Monoxide detectors were observed operational.

The following forms are to be updated and submitted to CCLD
-LIC500 Personnel Report
-LIC308 Designation of Administrative Responsibility
-LIC610E Emergency Disaster Plan
-An updated copy of Administrator Certificate(s)

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2022
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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