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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201295
Report Date: 03/28/2024
Date Signed: 03/28/2024 02:42:04 PM

Document Has Been Signed on 03/28/2024 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
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: 0DATE:
03/28/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Samuel Tet, AdminstratorTIME COMPLETED:
01:30 PM
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On 3/28/2024 at 11:30AM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct Pre-licensing Inspection. Upon arrival, LPA met with Samuel Tet Administrator, and explained the purpose of the visit. The facility currently has no clients.

LPA toured facility including but not limited to 3 bedrooms, 3 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 inside a cabinet. There is sufficient lighting throughout facility. Room temperature was maintained at 68 degrees F and hot water temperature was maintained at 117.3 degrees F. First-aid kit was observed to be complete. Smoke detectors and carbon monoxide were operational. Fire extinguisher was last purchase on 3/28/2024.

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 via email.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2024
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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