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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201432
Report Date: 01/31/2025
Date Signed: 01/31/2025 10:34:59 AM

Document Has Been Signed on 01/31/2025 10:34 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:LAKE CHABOT CARE HOMEFACILITY NUMBER:
019201432
ADMINISTRATOR/
DIRECTOR:		BRAR, NAVRAJFACILITY TYPE:
740
ADDRESS:2723 BARLOW DRIVETELEPHONE:
(510) 876-8404
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94546
CAPACITY: 6CENSUS: 6DATE:
01/31/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Administrator, Navraj BrarTIME VISIT/
INSPECTION COMPLETED:
10:55 AM
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On 1/31/2025 at 9:20 AM, Licensing Program Analyst (LPA) Ardalan Gharachorloo arrived to conduct pre-licensing inspection. LPA explained to Navraj Brar, Administrator the purpose of the visit. This pre licensing is being conducted due to a change in ownership (CHOW) of the facility.

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. A comfortable temperature is maintained at 71 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 111 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. Centrally stored medication and sharps were locked and inaccessible to residents.

Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 01/31/2025. Emergency Disaster Plan was last posted on 09/05/2024. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 12/18/2024. LPA reviewed 5 residents records and 5 staff records; all were complete. LPA also reviewed a sample of resident’s medications.

No issues noted during inspection. LPA 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: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Ardalan Gharachorloo
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2025
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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