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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601455
Report Date: 07/17/2020
Date Signed: 07/20/2020 01:54:39 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: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:
07/17/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Xiang LingTIME COMPLETED:
05:00 PM
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On 07/17/2020 at 4:00 pm, Licensing Program Analyst (LPA) Luisa Fontanilla conducted a Face time Health and Safety check via tele-visit as a result of the department receiving a Priority 1 complaint during the COVID 19 shelter in place order.

Facility has an approved fire clearance for 3 non ambulatory and 11 ambulatory residents with (1) hospice waiver. LPA toured facility with Administrator, including but not limited to 6 resident rooms, common areas, dining, laundry room and kitchen. Residents appeared to be safe and there are no imminent health and safety concerns observed. However, LPA observed 5 residents in the dining room using wheelchairs. One resident was in bed during the tour. Administrator confirmed with LPA that all 6 residents are non ambulatory. LPA reminded Administrator that the fire clearance is approved for 3 non ambulatory only. Administrator states that he has applied for more ambulatory rooms for the past 4 years. However, the fire department has not come out yet to conduct inspection.

As of this visit, LPA is not issuing a citation on fire clearance violation pending facility file review in the office. Citations/civil penalty might be assessed in the future depending on the result of file review.
Due to COVID 19 shelter in place order, Administrator was not physically available to sign this report.

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

DATE: 07/17/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2020
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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