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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601507
Report Date: 04/18/2025
Date Signed: 04/18/2025 12:35:09 PM

Document Has Been Signed on 04/18/2025 12:35 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:OAKCREEKFACILITY NUMBER:
015601507
ADMINISTRATOR/
DIRECTOR:		ROSELINE R. PRASADFACILITY TYPE:
740
ADDRESS:6127 E. CASTRO VALLEY BLVD.TELEPHONE:
(510) 889-7515
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94552
CAPACITY: 38TOTAL ENROLLED CHILDREN: 0CENSUS: 33DATE:
04/18/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:05 AM
MET WITH:Roseline R. Prasad, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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On 04/18/2025 at 10:05 AM, Licensing Program Analyst (LPA) Ardalan Gharachorloo arrived unannounced to conduct a case management visit regarding an incident that happened on 04/07/2025. LPA met with Roseline Prasad, Executive Director and explained the purpose of the visit.

LPA received a special incident report regarding an altercation between R1 and R2 that resulted in R1's hip fracture. ED stated that the incident happened during shift change on 04/07/2025 at 2:30 PM. R1 was transported to hospital and was admitted for hip fracture. LPA spoke with Executive Director and the Resident Care Coordinator (S1) , and reviewed the incident report with them. LPA also toured R1 and R2's rooms. Both residents were in their rooms. LPA requested and reviewed the following documents during the visit: R1 and R2's Physician reports, care plans, Interdisciplinary progress notes for both residents, Staff schedule for 04/2025, Shift schedule, and doctors reports related to the incident. LPA's Review of the progress notes revealed that the responsible parties were called and notified regarding the incident.

LPA also interviewed ED who stated that there is a regular check-ins scheduled for R1 and R2 every 15 minutes. ED stated that there is a log that documents the check-ins completed by the caregivers. LPA reviewed the log during the visit.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
Yvonne Flores-LariosTELEPHONE: (510) 286-0517
Ardalan GharachorlooTELEPHONE: (510) 286-4201
DATE: 04/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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