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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200755
Report Date: 10/28/2022
Date Signed: 10/28/2022 04:14:37 PM


Document Has Been Signed on 10/28/2022 04:14 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
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: 79DATE:
10/28/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Dillon Cagulada, AdministratorTIME COMPLETED:
04:20 PM
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On 10/28/22 at 3:45PM, 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 requested staff schedules to be submitted to CCL by 10/31/22. Total of 8 residents from GLG had moved in to Sunrise, 1 of them was picked up to Piedmont Gardens at 1pm today. 7 residents are currently living at Sunrise. LPA interviewed 3 residents who stated that they felt safe living at Sunrise, they were fed well and needs were met.

Food, paper, PPE supplies were adequate.

There was no imminent health/safety concerns on today's date.

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: 10/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2022
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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