<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201384
Report Date: 07/08/2025
Date Signed: 07/15/2025 11:43:58 AM

Document Has Been Signed on 07/15/2025 11:43 AM - 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:ECOLUX ASSISTED LIVINGFACILITY NUMBER:
079201384
ADMINISTRATOR/
DIRECTOR:		VERMA, BHARATFACILITY TYPE:
740
ADDRESS:158 MIRA VISTA DRTELEPHONE:
(650) 665-0894
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 6CENSUS: 5DATE:
07/08/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Berthgeline Corpuz, CaregiverTIME VISIT/
INSPECTION COMPLETED:
07:35 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
*This is an amended report from visit on 07/08/2024-LPA issued correct deficiencies on LIC809 Annual Continuance Report dated 07/15/2025

On 07/08/2025 at 11:00AM, Licensing Program Analyst (LPA) T. Syess-Gibson conducted an unannounced 1-Year Required inspection. LPA met with Berthgeline Corpuz, caregiver and explained the purpose of the visit. Berthgeline contacted the administrator via phone. Administrator, Bharat Verma arrived at approximately 12:26PM. The Administrator currently holds a certificate #6072069740 that expires on 05/08/2026. The facility’s fire clearance was approved for six (6) non-ambulatory residents.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility has six (6) bedrooms and three (3) bathrooms. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature is maintained at 78 degrees Fahrenheit. LPA observed lighting in all rooms is adequate for the comfort and safety of the residents. Residents’ bathrooms are equipped with grab bars. Hot water temperature in the shared clients’ bathroom was measured at 117.1 degrees Fahrenheit. 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 purchased on 06/12/2024. Emergency Disaster Plan was last posted on 07/08/2025. First aid kit was observed to be complete.

Continue on LIC809C

NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Tonica Syess-Gibson
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/08/2025
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 8
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 8
Document Has Been Signed on 07/08/2025 07:23 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 07/08/2025 at 04:58 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ECOLUX ASSISTED LIVING
FACILITY NUMBER: 079201384

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type A
Section Cited
CCR
87355(d)(3)
(d) All individuals subject to criminal record review shall be fingerprinted and sign a Criminal Record Statement (LIC 508 [Rev. 1/03]) under penalty of perjury. (3) The licensee shall submit these fingerprints to the California Department of Justice, along with a second set of fingerprints for the purpose of searching the records of the Federal Bureau of Investigation, or comply with Section 87355(c), prior to the individual's employment, residence, or initial presence in the facility.
This requirement is not met as evidenced by:


Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above by having two (2) individuals in the facility who were not fingerprinted which poses an immediate health and safety risk to persons in care. LPA asked that they leave the facility and not return until they are fingerprinted and associated. .
POC Due Date: 07/09/2025
Plan of Correction
1
2
3
4
Administrator agreed to submit a plan to obtain fingerprint clearance for individuals in the facility and send to CCLD by POC date.
Civil penalty of $200.00 is being assessed today.
Deficiency Dismissed
Type A
Section Cited
CCR
87618(b)(3)(B)
87618 Oxygen Administration - Gas and Liquid
(b) In addition to Section 87611(b), the licensee shall be responsible for the following: (3) Ensuring that the use of oxygen equipment meets the following requirements: (B) "No Smoking-Oxygen in Use" signs shall be posted in the appropriate areas.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by not having “No Smoking-Oxygen in Use” signs posted which poses an immediate health and safety risk to persons in care.
POC Due Date: 07/09/2025
Plan of Correction
1
2
3
4
Administrator agreed to post signs in appropriate areas and send CCLD photos by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Tonica Syess-Gibson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2025


LIC809 (FAS) - (06/04)
Page: 5 of 8
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: ECOLUX ASSISTED LIVING
FACILITY NUMBER: 079201384
VISIT DATE: 07/08/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from LIC809.

LPA attempted to review three (3) staff records, one (1) out of three (3) were present at the facility and complete. LPA reviewed three (3) resident records which were complete.

LPA observed the following deficiencies:

  • At 11:18AM, LPA observed Medication (Terazosin and Daily Vite multivitamins) on table near computer in common area near the table residents were sitting eating breakfast
  • At 11:27AM, LPA observed two (2) out of the three (3) individuals inside facility during visit, were not fingerprint cleared and associated with the facility per guardian
  • At 11:53AM, LPA observed an unlocked kitchen cabinet with Simple Green all-purpose cleaner, Cascade platinum plus dishwasher pods, Fabuloso, Insect and Pest Control spray, Hydrogen Peroxide Topical Solution and Lysol Power Cleaner Concentrated multi-surface cleaner
  • At 11:59AM, LPA observed unlocked prescribed medication Nystop POW 100,000mg on stand near residents’ bed
  • At 12:00PM, LPA observed resident in bedroom with oxygen equipment near bed
  • At 12:08PM, LPA observed alterations between the linen closet and the master bedroom closet (expansion).
  • At 12:10PM, LPA observed unlocked laundry room with Tide Simply all in one laundry detergent


Continue on LIC809C
NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Tonica Syess-Gibson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025
LIC809 (FAS) - (06/04)
Page: 3 of 8
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: ECOLUX ASSISTED LIVING
FACILITY NUMBER: 079201384
VISIT DATE: 07/08/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from LIC809C
  • At 12:12PM, LPA observed an unlocked cabinet in shared restroom with Seventh Generation toilet bowl cleaner, Lysol disinfecting wipes and Clorox multi-surface cleaner
  • At 12:21PM, LPA observed a large black tent in garage with a complete bed with pillows, sheets and blankets, a foldaway bed, clothing hanging on a rack, bags and a Victoria super soft blanket in a clear carrying bag.
  • At 3:48PM, LPA observed during file review one (1) out of three (3) staff records were present at the facility and complete


LPA requested the following documents to be submitted to CCLD by 07/15/2025.

  • LIC9020 Resident Roster
  • LIC 308 Designation of Administrative Responsibility
  • Liability insurance.
  • LIC 500 Personnel Report(updated)
  • LIC 610E Emergency Disaster Plan.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

*An immediate civil penalty of $200.00 will be assessed on today's date*

($100.00 x 2 for each person’s presence in the facility and not fingerprint cleared)


Exit interview conducted. A copy of the appeal rights, LIC421BG, and this report provided

NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Tonica Syess-Gibson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025
LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 07/08/2025 07:23 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 07/08/2025 at 06:21 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ECOLUX ASSISTED LIVING
FACILITY NUMBER: 079201384

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
87465 Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored:
(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by having medications on table near computer, medications in an unlocked cabinet located in the kitchen and including but not limited to unlocked prescribed medication Nystop POW 100,000mg which was observed by LPA in the resident’s room on stand near bed, which poses an immediate health and safety risk to persons in care.
POC Due Date: 07/09/2025
Plan of Correction
1
2
3
4
Caregiver immediately removed medications and placed in a locked cabinet. Deficiency cleared during visit.
Type A
Section Cited
CCR
87309(a)
87309(a) Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by having an unlocked kitchen cabinet which contained Simple Green all-purpose cleaner, Cascade platinum plus dishwasher pods, Fabuloso, Insect and Pest Control spray, Hydrogen Peroxide Topical Solution and Lysol Power Cleaner Concentrated multi-surface cleaner Which poses an immediate health and safety risk to persons in care.
POC Due Date: 07/09/2025
Plan of Correction
1
2
3
4
Caregiver immediately locked the cabinet with solutions. Deficiency cleared during visit.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Tonica Syess-Gibson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2025


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 07/15/2025 11:44 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 07/09/2025 09:48 AM


Created By: Tonica Syess-Gibson On 07/08/2025 at 06:53 PM
Link to Parent Document Below:
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: ECOLUX ASSISTED LIVING
FACILITY NUMBER: 079201384

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85087(a)(3)
85087 Buildings and Grounds
(a) In addition to Section 80087, bedrooms must meet, at a minimum, the following requirements: (3) No room commonly used for other purposes shall be used as a bedroom for any person.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by having a complete bed with pillows, sheets, blankets, a foldaway bed, clothing hanging on a rack , bags and a Victoria super soft blanket in a clear carrying bag located in the garage under a big black tent which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2025
Plan of Correction
1
2
3
4
*This is an amended report from visit on 07/08/2025*

The correct deficiency was cited on Case Management dated 07/15/2025.
Type B
Section Cited
CCR
87412(f)
87412 Personnel Records
(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:



This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review , the licensee did not comply with the section cited above in not having all personnel records available to licensing to inspect which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2025
Plan of Correction
1
2
3
4
Administrator agreed to have all personnel records complete and available to licensing to inspect during normal business hours and will send a self-certifying email to CCLD by POC date
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Tonica Syess-Gibson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2025


LIC809 (FAS) - (06/04)
Page: 7 of 8
Document Has Been Signed on 07/15/2025 11:45 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 07/09/2025 10:23 AM


Created By: Tonica Syess-Gibson On 07/08/2025 at 07:00 PM
Link to Parent Document Below:
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: ECOLUX ASSISTED LIVING
FACILITY NUMBER: 079201384

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80086(a)
80086 Alterations to Existing Building or New Facilities
(a) Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in notifying CCLD of proposed alterations which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2025
Plan of Correction
1
2
3
4
*This is an amended report from visit on 07/08/2025*

The correct deficiency was cited on Case Management dated 07/15/2025.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Tonica Syess-Gibson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2025


LIC809 (FAS) - (06/04)
Page: 8 of 8