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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201283
Report Date: 09/14/2023
Date Signed: 09/14/2023 03:08:48 PM


Document Has Been Signed on 09/14/2023 03:08 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:NACILA SENIOR LIVINGFACILITY NUMBER:
019201283
ADMINISTRATOR:ROGERS, NICOLEFACILITY TYPE:
740
ADDRESS:2029 101ST AVENUETELEPHONE:
(925) 470-9078
CITY:OAKLANDSTATE: CAZIP CODE:
94603
CAPACITY:3CENSUS: 0DATE:
09/14/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Nicole Rogers, LicenseeTIME COMPLETED:
03:15 PM
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On 9/14/23 at 1:30 p.m., Licensing Program Analyst (LPA) Greg Clark arrived announced to conduct pre-licensing inspection. LPA met with Licensee Nicole Rogers and explained the purpose of the visit. The facility currently has no residents.

LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common areas and backyard. Bedrooms and living rooms were equipped with the proper furniture. Bathrooms were equipped with grab bars and non-skid mats. Linens and hygiene supplies were observed inside a cabinet. There is sufficient lighting throughout facility. Room temperature was maintained at 72 degrees F and hot water temperature at the kitchen sink was maintained at 115.4 degrees F. First-aid kit was observed to be complete. Smoke detectors and carbon monoxide were operational. Fire extinguisher was purchased on 7/13/2023.


No issues noted during inspection. LPAs observed that facility is 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: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory ClarkTELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2023
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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