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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601285
Report Date: 12/03/2021
Date Signed: 12/03/2021 04:18:22 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:RAKSHA 13 CARE HOMEFACILITY NUMBER:
015601285
ADMINISTRATOR:BHUTANI, SHALINIFACILITY TYPE:
740
ADDRESS:906 CORNELL AVENUETELEPHONE:
(510) 526-2533
CITY:ALBANYSTATE: CAZIP CODE:
94706
CAPACITY:13CENSUS: 12DATE:
12/03/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:TIME COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA) Delmundo conducted a health and safety inspection as a result of the Department receiving a complaint (15-AS-20211203145000). LPA met with Shalini Bhutani (administrator) and Nalini Bhutani (co-administrator) and informed the purpose of visit.

LPA toured the facility inside out with Shalini Bhutani. LPA inspected the living room, kitchen, dining area, bedrooms, bathrooms, side and backyards. The medication room was observed open with the med-tech inside the room working on the medications. Cleaning supplies were kept in a lock closet. Facility has sufficient lighting. Hallways and passageways were observed free of obstructions.

No deficiency cited during this visit.

Exit interview conducted and copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021
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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