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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200688
Report Date: 09/18/2024
Date Signed: 09/18/2024 12:33:35 PM


Document Has Been Signed on 09/18/2024 12:33 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: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: 3DATE:
09/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:Samuel Tet AdministratorTIME COMPLETED:
01:15 PM
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On 9/18/2024 at 8:34 AM, Licensing Program Analyst (LPA) Ardalan Gharachorloo arrived unannounced to conduct 1-Year Annual Required inspection. At 9:15 AM, LPA met with Administrator,Samuel Tet and explained the purpose of the visit.

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 72 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 118 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 06/21/2024.

LPA reviewed 3 residents records and 2 staff records; all were complete. LPA also reviewed a sample of resident’s medications. The following documents were reviewed:LIC 500 Personnel Report, LIC 610E, Emergency Disaster Plan, Liability Insurance, and Current Administrator’s Certificate.

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: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2024
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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