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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201146
Report Date: 06/09/2022
Date Signed: 06/09/2022 10:35:39 AM


Document Has Been Signed on 06/09/2022 10:35 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
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:
06/09/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Octavian Mahler, Licensee/AdministratorTIME COMPLETED:
10:50 AM
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On 6/9/2022 at 9:00AM, Licensing Program Analyst (LPA) G. Luk conducted a Pre-licensing Inspection to verify corrections were made. 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, and outdoor area. LPA observed fire extinguisher to be full and purchase receipt attached dated 5/16/2022. Carbon monoxide detector observed in operating condition. Hallway bathroom toilet has grab bar. LPA observed room 4's door handle has been repaired with no exposed hole. LPA observed knives drawer and kitchen sink cabinet had magnetic locks installed. LPA advised Licensee/Administrator that magnet key should not be accessible to residents. CCLD complaint poster was observed to be 20"x26". LIC610E has been updated to include two temporary shelter locations.

Front gate lock has been changed and gate is able to open from the inside. Side gate has a self closing latch. LPA observed a small fence was built parallel to the back fence between the two shed in the backyard for storing additional items (wheelchairs, wheel barrow, shovel, and extra equipment). LPA advised that Licensee/Administrator to update yard sketch to indicate a fence was created and send a copy to CAB analyst.

No issues noted during inspection. LPA observed that facility is ready to be licensed. This report will be submitted to the Centralized Application Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. 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: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2022
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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