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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200755
Report Date: 11/02/2022
Date Signed: 11/02/2022 10:26:34 AM


Document Has Been Signed on 11/02/2022 10:26 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
E BAY DELTA AC/SC, 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: 80DATE:
11/02/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Dillon Cagulada, AdministratorTIME COMPLETED:
10:35 AM
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On 11/2/22 at 9:05AM, Licensing Program Analyst (LPA) C. Lin conducted an unannounced case management visit as a result of receiving residents from Grand Lake Gardens (GLG) and check on residents. LPA met with Administrator and explained the purpose of the visit.

During visit, LPA obtained GLG resident's roster and staff schedules. Total of 7 residents from GLG are currently living in Sunrise, LPA met with 5 residents, 1 of them complained her money ($300) was missing. Administrator stated that the internal investigation has been ongoing. LPA advised Administrator to submit LIC624 and SOC341 to licensing and Ombudsman. Other than that, residents stated that their needs were met.

Adequate Food, paper, PPE supplies were observed. Staffing is stable.

Exit interview conducted with Administrator and copy of this report provided
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2022
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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