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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200717
Report Date: 09/01/2021
Date Signed: 09/01/2021 10:22:35 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:BAY HARBOUR CARE HOMEFACILITY NUMBER:
019200717
ADMINISTRATOR:RIVAS, DANIELAFACILITY TYPE:
740
ADDRESS:510 CENTRAL AVETELEPHONE:
(510) 523-0113
CITY:ALAMEDASTATE: CAZIP CODE:
94501
CAPACITY:12CENSUS: 3DATE:
09/01/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:09 AM
MET WITH:Daniela Rivas, AdministratorTIME COMPLETED:
10:30 AM
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On 09/01/21 at 10AM, Licensing Program Analysts (LPAs) Daisy Panlilio and Greg Clark conducted a Health and Safety check while delivering the complaint findings during visit.

During the health and safety check, LPAs observed a total of one staff and 3 residents at the facility. Administrator stated she is providing care and supervision to the residents until they are safely relocated to other facilities due to facility closure. Administrator stated she has contacted CCLD on 08/31/21 and was given instructions on facility closure procedures. LPAs toured facility with administrator, including but not limited to bedrooms, kitchen, bathroom, and common areas. Residents in care appear to be safe and there are no imminent health/safety concerns on today's date.

No deficiencies cited during the health and safety check. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021
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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