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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201283
Report Date: 11/19/2024
Date Signed: 11/19/2024 02:00:59 PM

Document Has Been Signed on 11/19/2024 02:00 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:NACILA SENIOR LIVINGFACILITY NUMBER:
019201283
ADMINISTRATOR/
DIRECTOR:		ROGERS, NICOLEFACILITY TYPE:
740
ADDRESS:2029 101ST AVENUETELEPHONE:
(925) 470-9078
CITY:OAKLANDSTATE: CAZIP CODE:
94603
CAPACITY: 3CENSUS: 0DATE:
11/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Nicole Rogers, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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On 11/19/24 at 1:15 PM, Licensing Program Analyst (LPA) Greg Clark arrived to conduct 1-Year Annual Required inspection. LPA met with Administrator, Nicole Rogers and explained the purpose of the visit. The facility currently does not have any residents.

LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the kitchen sink was measured at 117.3 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of non-perishable and 2 day of perishable foods. There is storage for medications and sharps to be locked and inaccessible to residents.

Smoke detectors, fire extinguisher and carbon monoxide detectors were in operating condition during visit. First aid kit was observed to be complete.

LPA reviewed 1 staff record and it was complete.


No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2024
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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