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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201295
Report Date: 02/22/2024
Date Signed: 02/22/2024 02:42:47 PM

Document Has Been Signed on 02/22/2024 02:42 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:REDWOOD ASSISTED LIVING LLCFACILITY NUMBER:
019201295
ADMINISTRATOR:TET, SAMUEL ALINFACILITY TYPE:
740
ADDRESS:18785 CARLTON AVENUETELEPHONE:
(510) 292-8610
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94546
CAPACITY: 6CENSUS: DATE:
02/22/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Samuel Alin TetTIME COMPLETED:
02:30 PM
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Facility Type: RCFE
Application Type: Initial
Capacity: 6
Census (if any clients in care): none
COMP II Participants: Samuel Alin Tet, admin/applicant
Interview Method: Telephone interview

On February 22, 2024, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program

2. Administrator plan needed; multiple locations

3. Staffing requirements & Training

4. Pre-licensing readiness/inspection

5. General provisions

SUPERVISORS NAME: Julia Kim
LICENSING EVALUATOR NAME: Dianne Ramos
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2024
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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