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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601284
Report Date: 05/29/2024
Date Signed: 05/29/2024 11:12:18 AM


Document Has Been Signed on 05/29/2024 11:12 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:RAKSHA 6FACILITY NUMBER:
015601284
ADMINISTRATOR:BHUTANI, NALANIFACILITY TYPE:
740
ADDRESS:1133 GARFIELD AVENUETELEPHONE:
(510) 558-7241
CITY:ALBANYSTATE: CAZIP CODE:
94706
CAPACITY:6CENSUS: 6DATE:
05/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
07:45 AM
MET WITH:Aesha Ahmed, Caregiver and Shalini Bhutani, Administrator. TIME COMPLETED:
11:30 AM
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On 05/29/2024 around 07:45 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct a required Annual Inspection. LPA was greeted by Aesha Ahmed, Caregiver (S1) and upon entry and explained the purpose of the visit. The Co-Administrator's Standard Certificate (#6011402740) expires 06/20/25. The facility’s fire clearance was approved for six (6) non-ambulatory residents; hospice waivers for two (2). Shalini Bhutani, Administrator (ADM), arrived about 09:45 AM to sign the report.

LPA observed four (4) clients having breakfast and two (2) in their bedrooms, LPA and S1 reviewed the Emergency Disaster Plan, and resident and staff files. LPA observed a visitor sign-in log at the entry. LPA and S1 toured the facility, including but not limited to bedrooms, bathrooms, kitchen, laundry area, common area, front and side yard. The facility consists of five (5) total bedrooms. All indoor passageways were free of obstruction. There weren't any bodies of water. The temperature for the residents was maintained at 79 degrees Fahrenheit (F) and the shared bathroom's water temperature was 107.8 F for the comfort and safety of all the residents. The bathrooms were safe, sanitary and in operating condition. Hand washing posters, paper towels, and soap observed at hand washing stations. Linen and hygiene supplies were available for all residents. PPE and paper goods remain sufficient. There was a minimum supply of 2-day perishables and 7-days of non-perishable foods.

continued on LIC809C...
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2024
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 3


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: RAKSHA 6
FACILITY NUMBER: 015601284
VISIT DATE: 05/29/2024
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...continued from LIC809

Smoke detectors/carbon monoxide were in operating condition during visit. Fire extinguishers last serviced on 01/22/24, first aid kit observed complete and fire drill was last conducted on 04/012/24.

Four (4) staff files reviewed all had criminal record clearance. Four (4) resident files reviewed were complete.

The following forms are to be updated:
-LIC500 Personnel Report
-LIC308 Designation of Administrative Responsibility
-LIC610 Emergency Disaster Plan to be updated

Exit interview conducted and a copy of this report provided to ADM.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024
LIC809 (FAS) - (06/04)
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