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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201068
Report Date: 05/21/2021
Date Signed: 05/21/2021 02:30:18 PM

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:MOUNTAINWOOD ASSISTED LIVING L.L.C.FACILITY NUMBER:
079201068
ADMINISTRATOR:GAO, SHANFACILITY TYPE:
740
ADDRESS:4348 SATINWOOD DRIVETELEPHONE:
(510) 813-8336
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY:6CENSUS: 4DATE:
05/21/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Gilbert Hernandez, Caregiver
Shan Gao, Administrator		TIME COMPLETED:
02:45 PM
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On 5/21/2021 at 9:15AM, Licensing Program Analysts (LPAs) G. Luk and L. Hall conducted an unannounced Pre-licensing Inspection. LPAs met with caregiver, Gilbert Hernandez and Licensee/Applicant, Shan Gao arrived an hour later. LPAs inspected the facility inside and out including but not limited to bedrooms, bathrooms, dining room, kitchen, living room, garage and outdoor area. The facility’s temperature was maintained at 68 degrees Fahrenheit (F). Hot water temperature was measured at 130.8 degrees F. Medications were centrally stored in a locked closet. However, LPAs found unlocked medication in refrigerator. No bodies of water observed. Disaster plan was completed on 2/1/2021. Home is clean and well ventilated with appropriate lighting. Licensee will provide LPA proof of liability insurance by 5/28/2021.

Fire extinguisher was serviced on 3/1/2021. Smoke and carbon monoxide detectors were observed. First aid kit was complete. Facility has a 7-day non-perishable and 2-day perishable food supply.

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

1. S1 was not associated to the current facility and S4 was not fingerprint cleared. Both staff needs to be fingerprint cleared and associated to the facility as soon as possible.

2. LPAs observed frozen food had labels inside the packaging which contaminated the frozen meats. LPAs advise licensee to clean and remove all the frozen items that has labels inside the packages.

3. LPAs observed the beds in the common area near the entrance way and in the garage. LPAs also observed the bed rails, used chairs, and other items that was along the side of the facility and needs to be stored property.

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2021
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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: MOUNTAINWOOD ASSISTED LIVING L.L.C.
FACILITY NUMBER: 079201068
VISIT DATE: 05/21/2021
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4. Hot water was corrected during inspection and re-measured at 109.9 degree F.

5. Administrator locked medications in the garage refrigerator during inspection.

6. Staff locked knives, gardening tools, and paint supplies during inspection.

Licensee/applicant will submit proof of corrections to CCL on/before 5/28/2020.

LPAs conducted Component III with Licensee during inspection. LPAs presented Component III Power Point and discussed the regulations embodied in the presentation.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2021
LIC809 (FAS) - (06/04)
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