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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201384
Report Date: 07/15/2025
Date Signed: 07/15/2025 12:58:32 PM

Document Has Been Signed on 07/15/2025 12:58 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: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:
07/15/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:55 AM
MET WITH:Bharat Verma, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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*This is an amended report from visit on 07/08/2025**
On 07/15/2025, LPA arrived unannounced to conduct a case management visit. LPA met with Administrator, Bharat Verma advised the purpose of visit. LPA issued the deficiencies under the correct regulation codes.

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: 07/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/15/2025
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 5
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)
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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: 07/15/2025
NARRATIVE
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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: 07/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
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: 07/15/2025
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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: 07/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2025
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 07/15/2025 12:58 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 07/15/2025 at 12:11 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: 07/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/15/2025
Section Cited
CCR
87203

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87203 Fire Safety
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
This requirement is not met as evidenced by:
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Administrator agreed to submit a LIC200 or send proof of no longer being used by sending CCLD a photo of cleared garage by POC date.
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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.
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Type B
07/15/2025
Section Cited
CCR87305(b)

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(b) The licensing agency may require the facility to acquire a local building inspection where the agency determines that a suspected hazard to health and safety exists.
This requirement is not met as evidenced by:
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Administrator agreed to submit an updated facility sktech, photo of alterations, and a formal letter explaing the purpose of alterations by POC date
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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.
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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: 07/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2025


LIC809 (FAS) - (06/04)
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