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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200687
Report Date: 10/30/2023
Date Signed: 10/30/2023 02:45:03 PM


Document Has Been Signed on 10/30/2023 02:45 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: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: 5DATE:
10/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:TET, SAMUEL, AdminstratorTIME COMPLETED:
03:00 PM
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On 10/30/23 at 9:30 AM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced required one year inspection and met with Administrator (ADM) Samuel Tet and explained the purpose of the visit. LPA observed two (2) males and (2) female in bed and one (1) female watching TV in the living room during the visit.

LPA inspected the facility inside and outside. Pathways were observed to be free of obstruction and fire hazards. The facility's fire clearance was approved for 4 non-ambulatory and two (2) bedridden residents which includes Hospice Waiver for two (2) residents. A written Emergency/Disaster plan dated 10/10/23 was posted on a bulletin board next to the dining area near a lane line phone. Centrally stored medications were locked in a plastic container above the wall next to the kitchen. Sharp objects were locked in the kitchen drawer next to the sink. Toxic chemicals were locked in the laundry area.

There was at least 7 days of nonperishable and 2 days of perishable foods. Facility room temperature was maintained at 71 degrees Fahrenheit. Hot water temperature was measured at 112.8 degrees Fahrenheit in the resident's bathroom. Resident's bathrooms have grab bars inside the shower and next to the shower. The facility has trained staff in Dementia Care, Medication, and Basic Training. Last Fire drill was conducted on 10/10/23. Fire extinguisher was fully charged and last inspected on 03/23/23. Smoke and Carbon monoxide detectors were operational.

LPA reviewed two staff and 2 resident files. Staff had criminal record clearances to work and are associated to the facility. Residents records all contain Admission Agreements, Physicians' reports, Consent forms, Personal rights, medical assessments, Needs and Services plans/Appraisals. The facility serves residents with Dementia. The facility has potentially dangerous objects locked and inaccessible to residents in care.


Report continue on LIC 809C...

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2023
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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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: EDEN ASSISTED LIVING
FACILITY NUMBER: 019200687
VISIT DATE: 10/30/2023
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Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 11/6/2022:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
Current Administrator’s Certificate

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023
LIC809 (FAS) - (06/04)
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