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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201146
Report Date: 05/13/2022
Date Signed: 05/13/2022 03:18:46 PM


Document Has Been Signed on 05/13/2022 03:18 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:ANASTASIAFACILITY NUMBER:
019201146
ADMINISTRATOR:MAHLER, OCTAVIANFACILITY TYPE:
740
ADDRESS:3646 EAST AVENUETELEPHONE:
(510) 692-7785
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY:6CENSUS: 0DATE:
05/13/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Octavian Mahler, Licensee/AdministratorTIME COMPLETED:
01:00 PM
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On 5/13/2022 at 8:45AM, Licensing Program Analyst (LPA) G. Luk conducted a Pre-licensing Inspection. LPA met with Licensee/Administrator, Octavian Mahler.

The facility's fire clearance was approved for 6 bedridden residents.



LPA toured facility including but not limited to resident's bedrooms, bathrooms, living room, kitchen, garage, and outdoor area. Resident's rooms were fully furnished and clean. Hot water was measured at 112.8 degrees F in the kitchen sink. LPA observed lighting in all rooms. LPA observed facility had some non-perishable and perishable food supply. Licensee will purchase additional food supplies once facility is licensed. Smoke detectors were observed in operating conditions. First aid kit was complete. Emergency disaster plan was complete.

The following will need to be completed before recommending licensure to Centralized Application Bureau (CAB):

1. Fire extinguisher was observed to be full, but unknown when it was last purchased or serviced. Licensee agreed to either provide a copy of the purchase receipt or have it serviced.

2. LPA observed front gate has a mechanical lock and facility does not have a fire clearance with locked perimeter. LPA requested licensee to either obtain property fire clearance or remove the mechanical lock on front gate.

(Continue on LIC809C...)

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ANASTASIA
FACILITY NUMBER: 019201146
VISIT DATE: 05/13/2022
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3. LPA observed facility only had smoke detectors and did not have carbon monoxide detector(s).

4. The toilet in the hallway bathroom does not have a grab bar.

5. No latch on side gate (right side of the building - front view). Room 4's door handle installed improperly which exposed the hole.

6. Backyard has some items that needs to be removed including exercise equipment, additional storage, wheelchairs, wheel barrow, shovel, and extra furniture in bedroom 1.

7. LPA observed knives were locked in the drawer with child lock only.

8. Facility currently only have 1 temporary shelter location. Per guidelines, facility must have two temporary shelter locations.

9. CCLD Complaint poster size was 10''x16'' and should be 20''x26''.

Licensee/Administrator will submit proof of corrections to CCLD on/before 5/30/2022.

Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022
LIC809 (FAS) - (06/04)
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