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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201433
Report Date: 10/10/2024
Date Signed: 10/10/2024 03:43:54 PM

Document Has Been Signed on 10/10/2024 03:43 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:GRAND LAKE VISTAFACILITY NUMBER:
019201433
ADMINISTRATOR/
DIRECTOR:		KOO, HASMINFACILITY TYPE:
740
ADDRESS:365 STATEN AVENUETELEPHONE:
(408) 202-2236
CITY:OAKLANDSTATE: CAZIP CODE:
94610
CAPACITY: 15CENSUS: 13DATE:
10/10/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Hasmin Koo, Administrator/ApplicantTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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On 10/10/2024 at 9:30AM, Licensing Program Analysts (LPAs) G. Luk and D. Doidge conducted a Pre-licensing Inspection. LPAs met with Administrator, Hasmin Koo and explained the purpose of the visit.


LPAs toured facility including but not limited to resident's bedrooms, bathrooms, common areas, dining area, kitchen, basement, and outdoor area. Bathrooms have grab bars and non-skid mats. LPAs observed facility has one week of non-perishable and two days of perishable food supplies available. Smoke detectors are interconnected with sprinkler system. Carbon monoxide detectors were observed. First aid kit was complete. Fire extinguishers were observed to be full and last serviced on 5/21/2024. Hot water was measured at 108.6 degrees F in the kitchen sink.

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

1. LPAs observed unlocked laundry detergent under the bathroom sink. Staff locked up the detergent during inspection.

2. LPAs observed some bedrooms does not have lamps and chairs available.

3. LPAs observed CCLD poster size is not 20" x 26".

4. LPAs observed facility stairwells does not have evacuation chairs.

5. LPAs observed bathrooms and hallways does not have night lights.

6. LPAs observed there was no planned activities posted at the facility.


(Continue on LIC809C...)
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2024
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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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: GRAND LAKE VISTA
FACILITY NUMBER: 019201433
VISIT DATE: 10/10/2024
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7. LPAs observed there was no theft and investigative procedures posted at the facility.
8. LPAs observed LIC610E section, "Plans for the facility to be self-reliant for a period of not less than 72 hours..." had minimal information.

Administrator/Applicant will submit proof of corrections to CCLD on/before 10/25/2024.
Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024
LIC809 (FAS) - (06/04)
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