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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440776
Report Date: 03/04/2024
Date Signed: 03/04/2024 03:02:19 PM


Document Has Been Signed on 03/04/2024 03:02 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:BAYWOOD COURTFACILITY NUMBER:
011440776
ADMINISTRATOR:MANJOT KAURFACILITY TYPE:
740
ADDRESS:21966 DOLORES STREETTELEPHONE:
(510) 733-2422
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94546
CAPACITY:72CENSUS: 49DATE:
03/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Manjot Kaur, AdminstratorTIME COMPLETED:
03:30 PM
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On 3/4/2024 at 9:45AM, Licensing Program Analyst (LPA) K. Nguyen conducted an unannounced 1-Year Required inspection. LPA met with Administrator, Manjot Kaur. The Administrator currently holds a certificate (#6062932740) that expires on 10/12/2024. The facility’s fire clearance was approved for seventy-two (72) non-ambulatory residents.

LPA toured the facility with Director of Operations including but not limited to bedrooms, bathrooms, kitchen, common areas. All outdoor and indoor passageways are kept free of obstruction. LPA did not observe any bodies of water. A comfortable temperature is maintained at 72 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom in the common area was measured at between 108 degrees Fahrenheit. Hot water temperature in resident's room was measured at 114.5 - 116 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods.

Facility has a fire system. Fire extinguisher was last serviced on 01/15/2024. Emergency Disaster Plan was last posted on 4/25/2023. First aid kit was observed to be complete. Fire drill was last conducted on 2/24/24.

Six (6) staff records were reviewed, and all staff have criminal record clearance and hold a current first aid certificate. LPA also reviewed five (6) resident records and a sample of residents' medication



No deficiencies cited during visit.

Exit interview conducted and a copy of this report provided via email.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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