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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201204
Report Date: 10/13/2022
Date Signed: 10/13/2022 04:24:06 PM

Document Has Been Signed on 10/13/2022 04:24 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:CASTRO VALLEY RESIDENTIAL CARE HOME LLCFACILITY NUMBER:
019201204
ADMINISTRATOR:SHWE, MA OHNMARFACILITY TYPE:
740
ADDRESS:1932 GROVE WAYTELEPHONE:
(510) 789-7064
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94546
CAPACITY: 3CENSUS: 0DATE:
10/13/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:LICENSEE/ADMINISTRATOR, MA OHNMAR SHWETIME COMPLETED:
04:20 PM
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Facility Type: RCFE
Application Type: Initial
Capacity: 3
Census (if any clients in care): 0
Infection Control Plan discussed? Yes

Method: Telephone call with CAB
COMP II Participants: Licensee/Administrator, Ma Shwe

Applicant/administrator participated in COMP II via telephone call with the analyst at CAB. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Staff qualifications and responsibilities
3. Applicant and Administrator qualifications
4. Program policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions
5. Grievances, Complaints, Community resources
6. Physical plant, food service
7. Application document review and technical assistance: Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator certificate, Financial verification, Pre-licensing inspection, Compliance history, Control of property
SUPERVISORS NAME: Darla Neeley
LICENSING EVALUATOR NAME: Biridiana Cisneros
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2022
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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