<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201138
Report Date: 03/28/2022
Date Signed: 03/28/2022 12:04:57 PM


Document Has Been Signed on 03/28/2022 12:04 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:ASSISTED GRACEFUL LIVINGFACILITY NUMBER:
019201138
ADMINISTRATOR:KHATU, MANALI SUHASFACILITY TYPE:
740
ADDRESS:3864 PRINCETON WAYTELEPHONE:
(650) 440-9797
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY:6CENSUS: 0DATE:
03/28/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Manali Khatu, AdministratorTIME COMPLETED:
11:15 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 03/28/2022 at 9:50am Licensing Program Analysts (LPAs) L. Hall and C. Fowler conducted an announced pre-licensing inspection. LPAs met with Manali Khatu, Administrator.

LPAs inspected the facility inside and out including but not limited to the bedrooms, bathrooms, common living areas, kitchen, and backyard. The facility has a total of five (5) bedrooms and two (2) bathrooms There is sufficient lighting around the facility. Residents rooms are equipped with the beds, chairs, and lighting. Residents rooms have proper bedding and linens. Passageways and hallways are free of obstruction. Hot water temperature is measured at 117 degrees Fahrenheit. Fire extinguisher is in compliance. Smoke detectors/carbon Monoxide detector are equipped around the facility. First aid kit is complete.

Prior to licensure, the following shall be corrected and submitted to CCLD by 04/01/2022..

- A photo of each bedroom containing a chest of drawers.
- A photo of the cabinet with a lock that will store sharps and medication.
- A photo of area in backyard near washer and dryer free of paint cans, door, and trash.

Issues were noted during inspection. LPA observed that facility is not ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAU. Additional requirements may still be required.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1