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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601429
Report Date: 03/29/2022
Date Signed: 03/29/2022 06:20:05 PM


Document Has Been Signed on 03/29/2022 06:20 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 4 CARE HOMEFACILITY NUMBER:
015601429
ADMINISTRATOR:BHUTANI, BHUMIFACILITY TYPE:
740
ADDRESS:616 STANNAGE AVENUETELEPHONE:
(510) 912-6244
CITY:ALBANYSTATE: CAZIP CODE:
94706
CAPACITY:6CENSUS: 5DATE:
03/29/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
06:09 PM
MET WITH:Administrator, Shalini BhutaniTIME COMPLETED:
06:30 PM
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On 03/29/2022 at 6:09 PM, Licensing Program Analyst (LPA) L. Holmes conducted an unannounced Health & Safety inspection. LPA met with Administrator, Shalini Bhutani.

LPA toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, medication closet, and outdoor area. Hot water temperature was measured at 108.4 degrees Fahrenheit in the bathroom and the common area thermostat was measured at 72 degrees Fahrenheit. 7-days of non-perishables and 2-days of perishable food supplies were present. Facility orders food supplies 1-2 times a week or more. Resident's medications were kept locked in the medication closet. Smoke and carbon monoxide detectors are combined and observed throughout the facility and the bedrooms. First-aid kit was complete. Fire extinguisher was observed to be full and last inspected 01/04/2022. No accessible bodies of water were observed. Indoor and outdoor passageways were free of obstruction. Mitigation plan on file and following COVID-19 guidelines.

No deficiencies are cited on this date.

Exit interview conducted. 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: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2022
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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