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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201338
Report Date: 01/25/2024
Date Signed: 04/05/2024 07:01:00 AM


Document Has Been Signed on 04/05/2024 07:01 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
CENTRALIZED APP UNIT, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814



FACILITY NAME:MOONRAKER VILLA SENIOR CARE 2FACILITY NUMBER:
019201338
ADMINISTRATOR:AKAOSUGI, YONGFACILITY TYPE:
740
ADDRESS:22052 MAIN STREETTELEPHONE:
(510) 776-6084
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:6CENSUS: 0DATE:
01/25/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Yong Akaosugi (Applicant/Administrator)TIME COMPLETED:
08:45 AM
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Component II completion: Successful

Facility Type: RCFE
Application Type: INITIAL
Capacity: 6
Census (if any clients in care): 0

COMP II Participants: Name -Yong Akaosugi (Applicant)/(Administrator)
Interview Method: Telephone interview

On January 25, 2024, Applicant/Administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant/administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of the
following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-Licensing Readiness
SUPERVISOR'S NAME: Darla NeeleyTELEPHONE: (916) -65-7817
LICENSING EVALUATOR NAME: Tammy EdwardsTELEPHONE: 916-651-9141
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2024
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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