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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200688
Report Date: 10/03/2023
Date Signed: 10/03/2023 01:45:22 PM


Document Has Been Signed on 10/03/2023 01:45 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:LAKE CHABOT ASSISTED LIVINGFACILITY NUMBER:
019200688
ADMINISTRATOR:TET, SAMUELFACILITY TYPE:
740
ADDRESS:18821 CARLTON AVETELEPHONE:
(888) 818-8101
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94546
CAPACITY:3CENSUS: 2DATE:
10/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Samuel Tet, LicenseeTIME COMPLETED:
02:00 PM
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On 10/3/2023 at 09:45 am Licensing Program Analysts (LPA) K. Nguyen arrived unannounced to do an annual inspection. LPA met with Licensee Samuel Tet and explained the purpose of the visit.

LPA inspected the facility inside and out. There is no body of water. Physical plant is consistent with the facility sketch received by Central Application Bureau (CAB) and approved by the fire department. LPA inspected the living room, dining area, kitchen, bedrooms, hallways, bathrooms, and backyards. Bedrooms were observed appropriately furnished with adequate lighting and drawers. The facility has sufficient towels, extra bed sheets and comforters. Equipment and supplies for residents' personal hygiene are available and on site. Dinner and silver wares were observed to be sufficient for residents' use. Food supplies checked and observed good for seven days of non-perishables. The facility was observed equipped with refrigerator, microwave, dishwasher, washer, and dryer. Cabinet for knives, cleaning supplies, and central storage for medications were observed with locks. Activity supplies were available. Outdoor activity space was observed furnished with tables, chairs, and shade. The facility has a mitigation plan. The water temperature measured 112-degree Fahrenheit. Fire extinguishers were observed fully charge and tags showed serviced in March 2023.

No deficiencies cited during the visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2023
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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