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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200992
Report Date: 09/17/2020
Date Signed: 09/17/2020 09:39:19 AM

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:CASA RIVERA ASSISTED LIVING & MEMORY CARE LLCFACILITY NUMBER:
079200992
ADMINISTRATOR:RIVERA, VERONICAFACILITY TYPE:
740
ADDRESS:1272 DONALD DRTELEPHONE:
(510) 685-0493
CITY:RODEOSTATE: CAZIP CODE:
94572
CAPACITY:5CENSUS: DATE:
09/17/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Veronia Rivera, Administrtaor TIME COMPLETED:
09:15 AM
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On 09/17/2020 LPA J. Jackson conducted an announced tele-visit on this date. LPA advised Administrator Veronica to correct the items listed below on 09/08/2020:
Complete First Aid Kit to include the following: thermometer, tweezers, and scissors
Personal Rights Poster

On this date LPA observed all items were corrected.

LPA observed that facility is ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed, and is subject to final approval by CAU. Additional requirements may still be required.

Exit interview conducted and a copy of this report will be emailed to Administrator Veronica Rivera.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jasmine JacksonTELEPHONE: (510) 285-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2020
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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