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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201106
Report Date: 12/15/2021
Date Signed: 12/15/2021 04:08:04 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:EASTBAY VILLASFACILITY NUMBER:
079201106
ADMINISTRATOR:SURIAO, MARINAFACILITY TYPE:
740
ADDRESS:1785 BILLINGS ROADTELEPHONE:
(925) 689-6551
CITY:CONCORDSTATE: CAZIP CODE:
94519
CAPACITY:6CENSUS: 4DATE:
12/15/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Marina SuriaoTIME COMPLETED:
02:00 PM
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On 12/15/2021, Licensing Program Analysts (LPAs) L. Ibo, J. Clancy- Czuleger arrived unannounced to conduct a pre-licensing inspection due to a change of ownership. LPAs met with Applicant Marina Suriao (Applicant/Administrator for Eastbay Villas), LPAs called Administrator Leonila Bunyi to informed the purpose of the visit, per Administrator Leonila Bunyi she is not available, L. Bunyi gave permission to LPAs to read report and give copy of the report to Applicant Marina Suriao.


LPA’s toured the entire premises indoors and outdoors. The facility has 6 bedrooms, 3 bathrooms, one story house per facility sketch. 5 bedrooms are designated for clients & 1 bedroom for facility staff. LPA’s observed 1 fire extinguisher which was in the kitchen. Smoke detectors and carbon monoxide detectors were observed operational. The facility received a fire clearance dated 9/15/2021 with an approval for a total capacity of 6 residents, approved for 1 non-ambulatory residents & 5 ambulatory.

LPAs observed a locked cabinet for centrally stored medications at the kitchen area. Kitchen and dining room floors are clean and sanitary, food preparation area has an operating ventilation fan, there are no pesticides, poisons, or other toxins stored in any food storage or preparation area, cleaning supplies are kept separate from food supply. The facility has a supply of 7 days of non-perishable and have at least 2 days perishable food. There are enough amounts of tableware, tables, dishes, and utensils. There are enough amounts of equipment for the storage & preparation of food. All equipment and dishes are clean and in good repair and there is at least 1 dining room convenient to the kitchen. Hot water temperature was tested at 118 degrees Fahrenheit. Refrigerator temperature was observed at 40 degrees Fahrenheit and freezer was observed at 0 degrees Fahrenheit.

...Continue LIC809C...
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021
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: EASTBAY VILLAS
FACILITY NUMBER: 079201106
VISIT DATE: 12/15/2021
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5 Bedrooms were observed furnished with a bed, bedding, and night stand, a chair, and a closet space. There were no bodies of water present at the facility. Outside pathways to security exit gate were unobstructed. There is confidential storage for personnel and resident records. There are games, activity supplies, and reading materials available. There is an outdoor area, that appears comfortable and furnished for residents to entertain friends and relatives. LPA’s observed the first aid kit was complete with manual.

During today's visit, LPAs reviewed LIC 610E Emergency disaster plan/Fire and Earthquake drill requirements with applicant. LPAs observed the facility had the necessary posters in place (Complaint poster, LTCO poster, Rights to Council, etc). COVID-19 posters were also displayed in the main entrance, common areas and the bathrooms.

Comp III was discussed with Applicant.

LPAs 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 with Applicant Marina Suriao and a copy of report was provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021
LIC809 (FAS) - (06/04)
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