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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601455
Report Date: 07/22/2020
Date Signed: 07/23/2020 08:09:20 AM

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:REDWOOD ROAD CARE HOMEFACILITY NUMBER:
015601455
ADMINISTRATOR:LIN, XIANG(DAVID)FACILITY TYPE:
740
ADDRESS:20112 REDWOOD ROADTELEPHONE:
(510) 703-8063
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94546
CAPACITY:14CENSUS: 6DATE:
07/22/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:25 PM
MET WITH:Xiang LinTIME COMPLETED:
05:00 PM
NARRATIVE
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On this day at 2 pm, LPA spoke with Administrator via telephone in connection with a case management tele visit conducted on 7/17/2020 on the facility's approved fire clearance.

Based on LPA's observation and Administrator's confirmation, facility has 6 non ambulatory residents at the time of tele visit. Facility's fire clearance is approved for 3 non ambulatory residents only.

Type A deficiency is cited from the California Code of Regulations Title 22. Civil penalty of $500.00 is being assessed.

Exit interview conducted with Administrator. A copy of this report and Appeal Rights were provided to Administrator via email.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2020
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: REDWOOD ROAD CARE HOME
FACILITY NUMBER: 015601455
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/23/2020
Section Cited

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Fire Clearance All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency
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and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.
(1) Nonambulatory persons.
Ths poses an immediate health and safety risk to clients in care.
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facility has 3 more non ambulatory residents.

Civil penalty of $500 is being assessed for fire clearance violation.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2020
LIC809 (FAS) - (06/04)
Page: 2 of 2