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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200751
Report Date: 07/23/2024
Date Signed: 07/23/2024 12:47:47 PM


Document Has Been Signed on 07/23/2024 12:47 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:EAST BAY LONGEVITY ASSISTED LIVINGFACILITY NUMBER:
019200751
ADMINISTRATOR:KAUNG, ALICEFACILITY TYPE:
740
ADDRESS:388 12TH STREETTELEPHONE:
(510) 808-7783
CITY:OAKLANDSTATE: CAZIP CODE:
94607
CAPACITY:49CENSUS: 4DATE:
07/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Chun Hang Ng, AdministratorTIME COMPLETED:
01:00 PM
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On 7/23/24 at 10:30 AM, Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Chun Hang Ng, Administrator and explained the purpose of the visit.

LPA toured the facility including but not limited to residents’ apartments, bathrooms, activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 70 degrees F. The hot water temperature in a hallway sink was measured at 118.8 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care.

Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 5/14/2024. First aid kit was observed to be complete.

LPA reviewed 4 residents records and 4 staff records, and all were complete. LPA also reviewed a sample of resident’s medications.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 7/30//24: LIC 610E Emergency Disaster Plan

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory ClarkTELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024
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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