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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011400514
Report Date: 03/22/2024
Date Signed: 03/22/2024 01:50:14 PM


Document Has Been Signed on 03/22/2024 01:50 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:PIEDMONT GARDENS #1FACILITY NUMBER:
011400514
ADMINISTRATOR:WITTMAN, DANIELFACILITY TYPE:
741
ADDRESS:110-41ST STREETTELEPHONE:
(510) 654-7172
CITY:OAKLANDSTATE: CAZIP CODE:
94611
CAPACITY:321CENSUS: 64DATE:
03/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Daniel Wittman, Excutive DirectorTIME COMPLETED:
02:00 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
On 3/22/2024 at 8:45 AM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Daniel Withman, Executive Director/ Zinnia Koch Director of Wellness and Assisted Living and explained the purpose of the visit. Administrator Certificate number: 6059871740 expire on 6/10/2025. Liability Insurance expire on 1/1/2025.

LPA inspected the facility including but not limited to resident apartments, bathrooms, dining rooms, common living areas, kitchen, and outside areas. The room temperature and lighting were adequate for the safety and comfort of the residents. Rooms were furnished appropriately and observed to be clean and in good repair. All rooms have private bathrooms, and showers on the 8th and 9th floor which were equipped with grab bars and safety/nonskid floors/mats. There was an adequate supply of 2-day perishable and 7-day non-perishable foods. Refrigerator temperature is measured at 35 degrees Fahrenheit. Freezer temperature was measured at -5 degrees Fahrenheit. Kitchen and food preparation areas were observed to be clean and in compliance. There were no bodies of water or fire safety hazards observed. All indoor and outdoor passageways were kept free of obstruction. Facility is equipped with smoke detectors, sprinklers, and fire alarm. Memory Care Unit doors were equipped with wander guard. Fire extinguishers throughout facility were fully charged and last inspected on 3/1/2024. Last Fire/Earthquake Emergency drill was conducted on 3/14/2024. The facility's fire clearance is approved for 321 residents. Administrator is on site at least 40 hours a week to oversee the business operation. There is an adequate number of trained staff to meet residents' needs during inspection. Staff assisting with activities of daily living and medications had the necessary training. LPA observed hot water temperature measured in residents’ apartments measured between 110–118 degree Fahrenheit.


LPA reviewed 6 residents records. LPA reviewed 8 staff records and 8 of 8 have current first aid training and associated to the facility. LPA reviewed a sample of resident’s medications.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2024
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 1