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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200771
Report Date: 10/21/2024
Date Signed: 10/21/2024 01:27:29 PM


Document Has Been Signed on 10/21/2024 01:27 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:OAKLEY ASSISTED LIVING LLCFACILITY NUMBER:
079200771
ADMINISTRATOR:LAKE, NICOLETTEFACILITY TYPE:
740
ADDRESS:531 O'HARA AVETELEPHONE:
(925) 219-6165
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY:6CENSUS: 6DATE:
10/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Nicolette Lake, AdministratorTIME COMPLETED:
02:00 PM
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On 10/21/2024 at 11:00AM, Licensing Program Analyst (LPA) T. Syess-Gibson conducted an unannounced 1-Year Required inspection. LPA met with Administrator, Nicolette Lake and explained the purpose of the visit. The Administrator currently holds a certificate (#7014095740) expires on 10/04/2025. The facility’s fire clearance was approved for five (5) non ambulatory and one (1) bedridden residents.

LPA toured facility with Nicolette including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 4 total bedrooms which all 4 bedrooms are occupied by the residents and four (4) bathrooms. Administrators occupy in-law unit in the back yard, residents do not have access to it. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. LPA observed an additional unit in the backyard where pool was originally (LPA obtained permit during visit). The unit isn't part of the licensed facility, it's a stand alone unit with a separate address. A comfortable temperature is maintained at 73 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 and private bathrooms were measured at 116.2 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum 7 day supply of nonperishable and 2 day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents.

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.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Tonica Syess-GibsonTELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2024
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: OAKLEY ASSISTED LIVING LLC
FACILITY NUMBER: 079200771
VISIT DATE: 10/21/2024
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Continued from LIC809.

LPA reviewed all six (6) resident records, four (4) staff records one and they all were complete

LPA reviewed a sample of medication during visit.

The following forms to be updated and submitted to CCLD by 10/28/2024:

· LIC 500 Personnel Report
· LIC 400 Affidavit Regarding Client/Resident Cash Resources
· LIC 402 Surety Bond
· LIC610E Emergency Disaster Plan
· LIC308 Designation of facility responsibility

No deficiencies observed during visit.

Exit interview conducted and a copy of this report provided to Nicolette Lake.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Tonica Syess-GibsonTELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2