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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440427
Report Date: 02/14/2025
Date Signed: 02/14/2025 12:09:39 PM

Document Has Been Signed on 02/14/2025 12:09 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:CHARITYS RESIDENCEFACILITY NUMBER:
011440427
ADMINISTRATOR/
DIRECTOR:		MARYANN AQUINO LAGURAFACILITY TYPE:
740
ADDRESS:2933 MONTEREY BLVDTELEPHONE:
(510) 482-2855
CITY:OAKLANDSTATE: CAZIP CODE:
94602
CAPACITY: 6CENSUS: 3DATE:
02/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Licensee Caridad AquinoTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Document Link IconOn 02/14/2025 at 09:20 AM, Licensing Program Analyst (LPA) David Doidge arrived to conduct 1-Year Annual Required inspection. LPA met Licensee Caridad Aquino explained the purpose of the visit.

During the visit, LPA toured facility including but not limited to the kitchen, dining room, resident bedrooms and bathrooms, front and back area of the facility, and common areas. Fire extinguisher was observed full and last inspected on 06/03/2024. Smoke detectors and carbon monoxide detectors were tested and observed functional. LPA observed the facility to be at a comfortable temperature at 72 degrees Farenheit. All indoor and outdoor passageways are kept free of obstruction. Hot water temperature was measured at 105.6 degrees Fahrenheit. LPA observed skid mats and grab bars in resident bathrooms. LPA observed sufficient furniture and lighting throughout the facility. There are no bodies of water present in or around the facility. LPA observed a sufficient supply of 7 day non-perishables and two day perishable food supplies.

LPA reviewed three (3) resident files and three (3) staff files; all were complete. The last fire and earthquake drills were conducted on 01/11/2025, performed monthly. Centrally stored medications were observed locked in a cabinet.

Continued on LIC 809-C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: David Doidge
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2025
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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: CHARITYS RESIDENCE
FACILITY NUMBER: 011440427
VISIT DATE: 02/14/2025
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Continue from LIC 809

LPA requested the following documents to be submitted to CCLD by 2/21/2025.

ยท Liability Insurance

No deficiencies observed or cited during this visit. .

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: David Doidge
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2025
LIC809 (FAS) - (06/04)
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