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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601429
Report Date: 06/23/2022
Date Signed: 06/23/2022 03:02:14 PM


Document Has Been Signed on 06/23/2022 03:02 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:
06/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Nalini Bhutani, AdministratorTIME COMPLETED:
03:10 PM
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On 06/23/2022 at 02:00 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct an Infection Control Inspection, LPA was greeted by one Caregiver upon entry and explained the purpose of the visit. The Administrator, Nalini Bhutani (ADM) was telephoned by the Caregiver and arrived about 30 minutes later.

Facility has a COVID-19 mitigation plan on file. LPA requested a staff and resident roster from ADM. LPA observed screening station at the entry with COVID-19 signage, sanitizer, and a visitor sign-in log. Advised to have masks available if needed. LPA toured the facility including, but not limited to common areas, bathrooms, bedrooms, and kitchen. LPA observed cough etiquette and hand washing signs posted. There was a sufficient supply of 2-day perishables and 7-day supply of non-perishable foods. All hand washing stations were equipped with soap and paper towels. ADM to provide covered garbage cans in shared areas including bathroom, add 20 seconds to handwashing signs, remove towel in shared bathroom, create an isolation cart and maintain a 30 day supply off PPE on site. Hot water temperature in the shared residents' bathroom was measured at 111.9 degrees Fahrenheit (F) and facility temperature was 72 degrees (F). Fire extinguisher last inspected 01/04/2022 and was observed full. Smoke/Carbon Monoxide detectors were observed operational.

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

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: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2022
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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