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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200734
Report Date: 11/06/2024
Date Signed: 11/06/2024 01:09:13 PM

Document Has Been Signed on 11/06/2024 01:09 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:BAY CARE ASSISTED LIVING LLCFACILITY NUMBER:
079200734
ADMINISTRATOR/
DIRECTOR:		ONYEAGOCHA, ROSE CFACILITY TYPE:
740
ADDRESS:2352 SHANNON AVETELEPHONE:
(510) 964-1669
CITY:SAN PABLOSTATE: CAZIP CODE:
94806
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 3DATE:
11/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:ROSE ONYEAGOCHA, ADMINISTRATORTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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On 11/6/2024 at 9:35am, Licensing Program Analyst (LPA) Carol Fowler conducted an unannounced 1-Year Required inspection. LPA met with Rose Onyeagocha and explained the purpose of the visit. The facility’s fire clearance was approved for five (5) non-ambulatory and one (1) bedridden residents.
LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area, garage and back yard. The facility consists of six (6) and three (3) bathrooms. No bodies of water observed. A comfortable temperature is maintained at 71 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 115.7 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 10/21/2024. Emergency Disaster Plan was last posted on 10/10/2024.

LPA reviewed three (3) staff files and were all complete. LPA reviewed all three (3) resident files and all were complete.


Continued on LIC809C.
Bennett FongTELEPHONE: (510) -62-2621
Carol FowlerTELEPHONE: (510) 622-2715
DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2024
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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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: BAY CARE ASSISTED LIVING LLC
FACILITY NUMBER: 079200734
VISIT DATE: 11/06/2024
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continue from LIC 809

LPA requested the following documents to be submitted to CCLD by 11/15/2024.
  • Resident Roster
  • LIC 308 Designation of Administrative Responsibility
  • LIC 309 Administrative Organization
  • LIC 500 Personnel Report
  • Liability Insurance


No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
LIC809 (FAS) - (06/04)
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