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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601284
Report Date: 06/07/2023
Date Signed: 06/07/2023 12:39:47 PM


Document Has Been Signed on 06/07/2023 12:39 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:RAKSHA 6FACILITY NUMBER:
015601284
ADMINISTRATOR:BHUTANI, NALANIFACILITY TYPE:
740
ADDRESS:1133 GARFIELD AVENUETELEPHONE:
(510) 558-7241
CITY:ALBANYSTATE: CAZIP CODE:
94706
CAPACITY:6CENSUS: 5DATE:
06/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH: Nalini Bhutani, AdministratorTIME COMPLETED:
01:00 PM
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On 06/07/23 at 09:40 AM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct a required Annual Inspection. LPA was greeted by Nalini Bhutani, Administrator (ADM) upon entry and explained the purpose of the visit. The Administrator's Standard Certificate (#6011402740) expires 06/20/23. The facility’s fire clearance was approved for six (6) non-ambulatory residents; hospice waivers for two (2).

The facility has an Infection Control Plan (ICP) on file. LPA reviewed the Emergency Disaster Plan, resident roster, resident and staff files. LPA observed a visitor sign-in log at the entry. LPA and ADM toured the facility, including but not limited to bedrooms, bathrooms, kitchen, laundry area, common area, front and side yard. Two (2) residents were watching television in the living room upon arrival. 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 75 degrees Fahrenheit (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. Add covered garbage cans to shared areas and paper towel dispenser/holders to wash stations. Linen and hygiene supplies were available for all residents. PPE and paper goods remain sufficient. There is 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: 06/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2023
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 2


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: 06/07/2023
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...continued from LIC809

Smoke detectors/carbon monoxide were in operating condition during visit. Fire extinguishers last serviced on 01/16/23, first aid kit observed complete and fire drill was last conducted on 04/2023.

Five (5) staff files reviewed all had criminal record clearance. Five (5) resident files reviewed were complete.

The following forms are to be updated:
-LIC500 Personnel Report
-LIC308 Designation of Administrative Responsibility (Reviewed)
-LIC610C Emergency Disaster Plan (Reviewed) and to be updated.
-An updated copy of Administrator Certificate(s)

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

DATE: 06/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2