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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601577
Report Date: 09/01/2023
Date Signed: 09/01/2023 02:46:51 PM


Document Has Been Signed on 09/01/2023 02:46 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:RN3 LOVING CARE HOME IVFACILITY NUMBER:
075601577
ADMINISTRATOR:WU, MEINAFACILITY TYPE:
740
ADDRESS:8320 BUCKINGHAM DRIVETELEPHONE:
(510) 439-7063
CITY:EL CERRITOSTATE: CAZIP CODE:
94530
CAPACITY:8CENSUS: 6DATE:
09/01/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrators Meina Wu and Enjie LiTIME COMPLETED:
03:00 PM
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On 09/01/2023, Licensing Program Analysts (LPA) J. Sampair arrived unannounced to conduct a health check as a result of a Priority 1 complaint. LPA met with Administrators Meina Wu and Enjie Li.

LPA toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, garage and outdoor area. Facility temperature was maintained at 71.5 degrees F. 7-days of non-perishable and 2-days of perishable food supplies were sufficient. Resident medications were kept locked in the cabinet. Smoke and Carbon monoxide detectors tested and were functional. First-aid kit was complete. Fire extinguisher was observed to be full and last serviced on 04/26/2023. There are no accessible bodies of water observed..

No citations issued.

Exit interview conducted and a copy of this report provided via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2023
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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