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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200687
Report Date: 07/17/2024
Date Signed: 07/17/2024 11:27:47 AM


Document Has Been Signed on 07/17/2024 11:27 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:EDEN ASSISTED LIVINGFACILITY NUMBER:
019200687
ADMINISTRATOR:TET, SAMUELFACILITY TYPE:
740
ADDRESS:18787 CARLTON AVETELEPHONE:
(510) 885-0557
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94546
CAPACITY:6CENSUS: 6DATE:
07/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Nadin GabiddonTIME COMPLETED:
11:50 AM
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On 07/17/2024 AM , Licensing Program Analyst (LPA) Ardalan Gharachorloo arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Staff, Nadine Gabbidon and explained the purpose of the visit. Administrator Samuel Tet was not be able to be present during the inspection.

LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. A comfortable temperature is maintained at 69 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 was measured at 107 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of non-perishable and 2 day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents.

Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 03/29/2024. Emergency Disaster Plan was last posted on 06/20/2024. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 06/20/2024.

LPA reviewed 5 residents records and 3 staff records; all were complete.LPA also reviewed residents medications. LPA also reviewed the Emergency disaster Plan, Liability insurance as well as the infection control plan.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Ardalan GharachorlooTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2024
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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