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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200755
Report Date: 03/09/2023
Date Signed: 03/09/2023 01:51:32 PM


Document Has Been Signed on 03/09/2023 01:51 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:SUNRISE ASSISTED LIVING OF OAKLAND HILLSFACILITY NUMBER:
019200755
ADMINISTRATOR:CAGULADA, DILLON RFACILITY TYPE:
740
ADDRESS:11889 SKYLINE BLVDTELEPHONE:
(510) 531-7190
CITY:OAKLANDSTATE: CAZIP CODE:
94619
CAPACITY:100CENSUS: 69DATE:
03/09/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Baraa Chalar, Memory Care CoordinatorTIME COMPLETED:
02:00 PM
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On 3/9/2023 starting at 12:45 PM, Licensing Program Analyst (LPA) Lizette Francisco arrived unannounced to conduct a case management visit on this date to verify if an individual is currently employed at the facility. LPA met with Memory Care Coordinator, Baraa Chalar and explained the purpose of the visit.

LPA interviewed staff. Based on evidence obtained during today’s visit, LPA has verified the individual is employed at the facility. LPA has advised the administrator to disassociate the individual from their roster and submit an updated LIC 500.

LPA provided Memory Care Coordinator a copy of Immediate Exclusion Letter

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 03/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2023
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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