015601429-6-5-2023-15-AS-LHOS-CSHVPQ-20230605163707

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015601429
Report Date: 06/05/2023
Date Signed: 06/05/2023 04:37:19 PM

Document Has Been Signed on 06/05/2023 04:37 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 4 CARE HOME		FACILITY NUMBER:	015601429
ADMINISTRATOR:	BHUTANI, BHUMI		FACILITY TYPE:	740
ADDRESS:	616 STANNAGE AVENUE		TELEPHONE:	(510) 912-6244
CITY:	ALBANY	STATE: CA	ZIP CODE:	94706
CAPACITY:	6	CENSUS: 6	DATE:	06/05/2023
TYPE OF VISIT:	Required - 1 Year	ANNOUNCED	TIME BEGAN:	02:35 PM
MET WITH:	Nalini Bhutani, Administrator		TIME COMPLETED:	04:55 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 06/05/23 at 02:36 PM, Licensing Program Analyst (LPA) L. Holmes arrived announced to conduct a required Annual Inspection. LPA was greeted by Care Staff and Nalini Bhutani, Administrator (ADM) upon entry and explained the purpose of the visit. The Standard Certificate (#6011402740) expires 06/20/23. The facility’s fire clearance was approved for six (6) non-ambulatory residents; hospice waivers for three (3). There is a contracted alarm company on record. The facility has an Infection Control Plan (ICP) on file. LPA reviewed the resident roster, staff files and Emergency Disaster Plan. LPA observed a visitor sign-in log at the entry. LPA and ADM toured the facility, including but not limited to bedrooms, bathroom, kitchen, laundry room, common area, front yard and backyard. The facility consists of four (4) total bedrooms. All indoor passageways were free of obstruction. There aren't any bodies of water. A comfortable temperature for residents was maintained at 72 degrees Fahrenheit (F), and the water temperature measured at 117.2 for the comfort and safety of all the residents. The bathroom was 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 is a minimum supply of 2-day perishables and 7-days of non-perishable foods. continued on LIC809C...

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha Holmes	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2023

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 4 CARE HOME	FACILITY NUMBER: 015601429
	VISIT DATE: 06/05/2023

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
26
27
28
29
30
31
32

...continued from LIC809

Smoke detectors/carbon monoxide were in operating condition during visit. Fire extinguisher 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, first-aid, and CPR. 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-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha Holmes	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2