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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200808
Report Date: 01/10/2025
Date Signed: 01/10/2025 05:10:32 PM

Document Has Been Signed on 01/10/2025 05:10 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:DOORSFACILITY NUMBER:
019200808
ADMINISTRATOR/
DIRECTOR:
ERIC UMALIFACILITY TYPE:
735
ADDRESS:1043 GILBERT STREETTELEPHONE:
(510) 363-8294
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 4CENSUS: 4DATE:
01/10/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Administrator Ramon Romo and Regional Lorenzo PennixTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
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On 1/10/2024 at 2:00 PM, Licensing Program Analyst (LPA) James Sampair arrived unannounced to conduct an annual required inspection. The LPA informed Staff Member Lucky Amenaghawon of the reason for visit. At approximately 2:30 PM, Administrator Ramon Romo and Regional Lorenzo Pennix arrived at the facility.

The LPA inspected the facility inside and outside with the staff and administrators. The inspection included the kitchen, dining area, living room, bedrooms, bathrooms, and yards. An adequate amount of food supplies were observed, more than enough for the required minimum of 2 days of perishable and 7 days of non-perishable. The central storage for medications and cleaning supplies were stored in locked cabinets.

Facility has a 2-in-1 smoke and carbon monoxide detector that was tested, and it was observed to function correctly. Facility conducts disaster and fire drills and records showed the most recent one was conducted on 1/1/2025. Fire extinguisher was fully charged and last serviced on 7/3/2024. The maximum hot water temperature in the kitchen was measured at 110.8 degrees Fahrenheit.

LPA reviewed 4 resident and 5 staff records.

No citation issued.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2025
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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