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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440776
Report Date: 02/06/2025
Date Signed: 02/06/2025 02:59:51 PM

Document Has Been Signed on 02/06/2025 02:59 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:BAYWOOD COURTFACILITY NUMBER:
011440776
ADMINISTRATOR/
DIRECTOR:
MANJOT KAURFACILITY TYPE:
740
ADDRESS:21966 DOLORES STREETTELEPHONE:
(510) 733-2422
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94546
CAPACITY: 72CENSUS: 46DATE:
02/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Manjot Kaur, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:20 PM
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On 02/06/2025 at 10:30 AM, Licensing Program Analyst (LPA) Ardalan Gharachorloo arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Manjot Kaur and explained the purpose of the visit.

LPA toured the facility including but not limited to 5 residents’ apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 72 degrees F. The hot water temperature in a residents’ shared bathroom was measured at 109 degrees Fahrenheit. Hot water temperature in resident's rooms were measured at 111- 112.5 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care.

Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 02/01/2025. Emergency Disaster Plan was last posted on 04/25/2023. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 11/09/2024.

LPA reviewed 6 residents records and 6 staff records, and all were complete. LPA also reviewed a sample of resident’s medications. The Following Documents were requested and reviewed during the visit :LIC 500 Personnel Report, LIC 610E Emergency Disaster Plan, Copy of the Liability Insurance and Current Administrator’s Certificate renewal documents.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Ardalan Gharachorloo
LICENSING EVALUATOR SIGNATURE: DATE: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/06/2025
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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