<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601285
Report Date: 12/16/2021
Date Signed: 12/16/2021 02:27:14 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:
12/16/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Nalini Bhutani, AdministratorTIME COMPLETED:
02:35 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 12/16/2021 at 1:25PM, Licensing Program Analyst (LPA) G. Luk conducted an unannounced Health & Safety inspection. LPA met with Administrator, Nalini Bhutani.

LPA toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, medication room, and outdoor area. Hot water temperature was measured at 117.1 degrees F in the kitchen sink. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Facility orders food supplies 1-2 times a week. Resident's medications were kept locked in the medication room. Smoke detectors are interconnected with the sprinkler system. Carbon monoxide detector observe. First-aid kit was complete. Fire extinguisher was observed to be full. There are no accessible bodies of water observed. Indoor and outdoor passageways are free of obstruction. Emergency disaster plan was last updated on 1/19/2021.

No deficiencies are being cited on this date.

Exit interview conducted. A copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1