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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200765
Report Date: 10/26/2023
Date Signed: 10/26/2023 03:20:55 PM


Document Has Been Signed on 10/26/2023 03:20 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:HARBOR BAY ASSISTED LIVING INCFACILITY NUMBER:
019200765
ADMINISTRATOR:NANCY MACHFACILITY TYPE:
740
ADDRESS:122 SHEFFIELD ROADTELEPHONE:
(510) 748-0407
CITY:ALAMEDASTATE: CAZIP CODE:
94502
CAPACITY:6CENSUS: 5DATE:
10/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Nancy Mach, AdministratorTIME COMPLETED:
03:50 PM
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On 10/26/23 at 12:30 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Nancy Mach and explained the purpose of the visit. The facility’s fire clearance was approved for 6 clients of which all can be non-ambulatory and 1 bedridden.

LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 4 total bedrooms of which 4 bedrooms are occupied by the residents. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. 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 kitchen was measured at 116 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 detector were in operating condition during visit. Fire extinguisher was last serviced on 5/25/23. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 6/23/23.

LPA reviewed 5 residents records and 5 staff records and 5 of 5 have current first aid training and are associated to the facility. LPA reviewed a sample of resident’s medications.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 11/02/2023: LIC 610E Emergency Disaster 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: Gregory ClarkTELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2023
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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