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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200537
Report Date: 12/23/2024
Date Signed: 12/23/2024 04:47:53 PM

Document Has Been Signed on 12/23/2024 04:47 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:VITAFACILITY NUMBER:
079200537
ADMINISTRATOR/
DIRECTOR:		BUYNEVICH, TATYANAFACILITY TYPE:
740
ADDRESS:4012 BLACKSMITH CIRTELEPHONE:
(925) 516-6470
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
12/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Carmen Benitez, CaregiverTIME VISIT/
INSPECTION COMPLETED:
05:05 PM
NARRATIVE
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On 12/23/2024 at 2:52PM, Licensing Program Analyst (LPA) T. Syess-Gibson conducted an unannounced 1-Year Required inspection. LPA met with Caregiver Silvia Salazar, spoke with Administrator, Tatyana Buynevich via telephone, and explained the purpose of the visit. The Administrator currently holds a certificate (#6033319740) that expires on 01/4/2025. The facility’s fire clearance was approved for six (6) non-ambulatory residents.

LPA toured the facility with Caregiver including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of six (6) bedrooms and three (3) bathrooms. All outdoor and indoor passageways are kept free of obstruction. LPA did not observe any bodies of water. A comfortable temperature is maintained at 69 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 119.0 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 09/05/2024. Emergency Disaster Plan was last posted on 08/01/2024. First aid kit was observed to be complete. Fire drill was last conducted on 11/10/2024.

Continued on LIC809C.
Harpreet HumpalTELEPHONE: (510) 285-3928
Tonica Syess-GibsonTELEPHONE: (510) 414-0641
DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: VITA
FACILITY NUMBER: 079200537
VISIT DATE: 12/23/2024
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Continued from LIC809.

Four (4) staff records were reviewed, all staff records were complete. LPA reviewed five (5) resident records, and they were current and complete.

LPA requested the following documents to be submitted to CCLD by 12/30/2024.

· LIC 308 Designation of Administrative Responsibility
· LIC 309 Administrative Organization
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan (last page)
· Liability Insurance

No deficiencies cited during visit.

Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Tonica Syess-GibsonTELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024
LIC809 (FAS) - (06/04)
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