<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201204
Report Date: 11/02/2022
Date Signed: 11/02/2022 12:35:01 PM

Document Has Been Signed on 11/02/2022 12:35 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: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:
11/02/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:56 AM
MET WITH:Shwe, Ma Ohnmar, AdminstratorTIME COMPLETED:
12:50 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 11/02/22 at 9:50 AM, Licensing Program Analysts (LPAs) K. Nguyen arrived unannounced to conduct Pre-licensing Inspection. Upon arrival, LPAs met with Ma Ohnmar Shwe Administrator, and explained the purpose of the visit. The facility currently has no clients.

LPA toured facility including but not limited to 2 bedrooms, 1 bathrooms, kitchen, common areas and backyard. Bedrooms and living rooms were equipped with the proper furniture. Bathrooms were equipped with grab bars and non-skid mats. Linens and hygiene supplies were observed. There is sufficient lighting throughout facility. Room temperature was maintained at 73 degrees F and hot water temperature was maintained at 110 degrees F. First-aid kit was observed to be complete. Smoke detectors and carbon monoxide were operational. Fire extinguisher was last serviced on 9/28/2022.

LPA conducted Component III and COVID-19 protocol consultation with Administrator. Facility has implemented COVID-19 screening at front entrance.

No issues noted during inspection. LPAs observed that facility is ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed, and is subject to final approval by CAU. Additional requirements may still be required.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1