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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200755
Report Date: 05/04/2023
Date Signed: 05/04/2023 11:15:34 AM


Document Has Been Signed on 05/04/2023 11:15 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
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: 76DATE:
05/04/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Steve Lackern, Regional Director of Resident CareTIME COMPLETED:
11:25 AM
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 On 5/4/2023 at 9:30AM, Licensing Program Analyst (LPA) K. Nguyen conducted an unannounced Case Management visit to clarify/ gather information of any new changes that management made. LPA met with Steve Lackern, Regional Director of Resident Care and explained the purpose of the visit. Administrator Dillion Cagulada was not available, but was informed by Steve the purpose of the visit. Dillion gave verbal permission for Steve to sign the report.

LPA interviewed Steve, and obtained current staff / resident roster, and residents/ residents family members/ team members notification letter.

No deficiencies issued during the visit and a copy of this report is provided via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2023
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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