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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200859
Report Date: 03/29/2023
Date Signed: 03/29/2023 03:17:58 PM

Document Has Been Signed on 03/29/2023 03:17 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:ROYAL OAK ST ADULT RESIDENTIAL FACILITY LLCFACILITY NUMBER:
019200859
ADMINISTRATOR:HOLLINQUEST, STEPHANIEFACILITY TYPE:
735
ADDRESS:10421 ROYAL OAK STTELEPHONE:
(510) 626-4186
CITY:OAKLANDSTATE: CAZIP CODE:
94605
CAPACITY: 6CENSUS: 5DATE:
03/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Terrance Thompson, AdministratorTIME COMPLETED:
03:20 PM
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On 3/29/23 at 12:30 PM, Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Co-Administrator, Terrance Thompson and explained the purpose of the visit. The facility’s fire clearance was approved for 6 ambulatory residents.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and back decks. The facility consists of 4 total bedrooms which 3 bedrooms are occupied by the residents and 1 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for residents is maintained at 70 degree Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Hot water temperature in the kitchen was measured at 116.1 degrees Fahrenheit. All toilets, hand washing and bathing are safe, sanitary and in operating condition. The supply of extra hygiene were available for residents. There is a minimum of one-week supply of non-perishables and 2-day perishables food supply.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 9/16/22. Emergency Disaster Drills and Fire drills are conducted and documented monthly. The last drill posted on 2/26/23. First aid kit was observed to be complete.

At 1:15 PM 5 of 5 resident records were reviewed. At 2:00 PM 5 staff records were reviewed and 5 of 5 have current first aid training and are associated to the facility. A sample of 2 resident’s medications were reviewed.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE: DATE: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/29/2023
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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