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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201129
Report Date: 11/17/2022
Date Signed: 11/17/2022 09:58:15 AM

Document Has Been Signed on 11/17/2022 09:58 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:CONNECTED LIVING OAKLANDFACILITY NUMBER:
019201129
ADMINISTRATOR:TRAIL, SARAFACILITY TYPE:
740
ADDRESS:1724 FILBERT STTELEPHONE:
(925) 826-6830
CITY:OAKLANDSTATE: CAZIP CODE:
94607
CAPACITY: 3CENSUS: 1DATE:
11/17/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Sara Trail, AdministratorTIME COMPLETED:
10:10 AM
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On 11/17/22 approximately at 8:30 am, Licensing Program Analyst (LPA) C. Lin arrived unannounced to conduct a proof of correction (POC) visit for the deficiencies cited on 11/3/2022. LPA met with Administrator and explained the purpose of the visit.

During visit, LPA observed knives were locked, fire extinguisher was new purchased on 11/9/2022, completed physician's report, pre-admission appraisal, and admission agreement were observed.

Deficiency of water temperature (87303(e)(2) was observed 124.7 degree F today. A civil penalty has been assessed from 11/11/2022 to 11/17/2022 at $100 x 7 = $700. Plan and proof of correction was discussed with Administrator.

Civil Penalties will continue to be assessed daily until corrected.

No deficiencies are being cited on this date.

Administrator was not available while conducting exit interview and authorized staff member Richard Felix to sign on this report and civil penalty page (LIC421FC), and a copy of this report and appeal rights provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2022
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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