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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200510
Report Date: 08/08/2024
Date Signed: 08/08/2024 10:50:47 AM

Document Has Been Signed on 08/08/2024 10:50 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:CNS COURTYARD #122FACILITY NUMBER:
019200510
ADMINISTRATOR/
DIRECTOR:		ROSCOE, ALEXANDRA RFACILITY TYPE:
735
ADDRESS:1465 65TH STREET, #122TELEPHONE:
(510) 788-4924
CITY:EMERYVILLESTATE: CAZIP CODE:
94608
CAPACITY: 2CENSUS: 2DATE:
08/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Remo Lyvkas CabunocTIME VISIT/
INSPECTION COMPLETED:
11:05 AM
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On 08/08/2024 at 9:15 AM., Licensing Program Analysts (LPAs) Ardalan Gharachorloo and David Doidge arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Administrator,Remo Lyvkas Cabunoc and explained the purpose of the visit

LPAs toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. A comfortable temperature for clients is maintained at 70 -degree Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 108-degree Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. The supply of extra hygiene was available for clients. There is a minimum of one-week supply of non-perishables and 2-day perishables food supply.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 03/14/2024. Emergency Disaster Plan was last posted on 01/30/2024. First aid kit was observed to be complete. Fire drill was last conducted on 07/10/2024.

LPAs reviewed 2 clients’ records and 5 staff records, and all were complete. Clients medications were reviewed. The following documents were reviewed during the visit: LIC 500 Personnel Report,LIC 400 Affidavit Regarding Client/Resident Cash Resources, and Emergency Disaster Plan.

No deficiencies were cited during this inspection. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Ardalan Gharachorloo
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2024
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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