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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 02:42:31 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:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Samuel Tet, Administrator TIME COMPLETED:
03:00 PM
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On today date Licensing Program Analyst (LPA) K. Nguyen conducted a Comp III and met with Samuel Tet, Administrator(AD). After the presentation AD stated that AD understand the materials that are presented in Comp III.


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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