<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201065
Report Date: 04/06/2021
Date Signed: 04/06/2021 04:23:56 PM

Document Has Been Signed on 04/06/2021 04:23 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:OAKLEY ASSISTED LIVING II , LLCFACILITY NUMBER:
079201065
ADMINISTRATOR:LAKE, NICOLETTEFACILITY TYPE:
740
ADDRESS:1449 BUTTONS CTTELEPHONE:
(925) 219-6165
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 6CENSUS: 0DATE:
04/06/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Nicolette LakeTIME COMPLETED:
04:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 04/06/2021 Licensing Program Analyst (LPA) Leslie Ibo made a scheduled visit to this facility for the purpose of completing a Pre-licensing inspection. LPA met with Applicant Nicolette Lake . LPA observed no residents were present during today’s visit.

At 11:00 AM, LPA toured the entire premises indoors and outdoors. The facility has 6 bedrooms, 4 bathrooms including 1 staff bathroom, 3 residents’ bathrooms, single story house per facility sketch. 6 bedrooms are designated for residents. LPA observed 1 fire extinguisher which was in the kitchen. Smoke detectors and carbon monoxide detectors were observed operational. The facility received a fire clearance dated 03/02/2021 with an approval for a total capacity of 6 residents, approved for 4 non-ambulatory & 2 bedridden.

LPA observed a locked cabinet for centrally stored medications at the kitchen area. Kitchen and dining room floors are clean and sanitary, food preparation area has an operating ventilation fan, there are no pesticides, poisons, or other toxins stored in any food storage or preparation area, cleaning supplies are kept separate from food supply. The facility has a supply of 7 days of non-perishable and LPA advised to have at least 2 days nonperishable food as soon as they admitted first residents. There are enough amounts of tableware, tables, dishes, and utensils. There are enough amounts of equipment for the storage & preparation of food. All equipment and dishes are clean and in good repair and there is at least 1 dining room convenient to the kitchen. Hot water temperature was tested at 120 degrees Fahrenheit. Refrigerator temperature was observed at 40 degrees Fahrenheit and freezer was observed at 0 degrees Fahrenheit.

Continue LIC809C...
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 04/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/06/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: OAKLEY ASSISTED LIVING II , LLC
FACILITY NUMBER: 079201065
VISIT DATE: 04/06/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
6 Bedrooms were observed furnished with a bed, bedding, and night stand, a chair, and a closet space. LPA observed 4 out of 6 bedrooms do not have closet but has appropriate dresser and drawers, applicant then ordered portable closets for the 4 bedrooms, receipt was sent to LPA. There were no bodies of water present at the facility. Outside pathways to security exit gate were unobstructed. There is confidential storage for personnel and resident records. There are games, activity supplies, and reading materials available. There is an outdoor area, that appears comfortable and furnished for residents to entertain friends and relatives. LPA observed the first aid kit was complete with manual. All exit doors in the facility are equipped with auditory signals. LPA verified there is an active telephone line in the facility, which is currently operating.

During today's visit, LPA reviewed LIC 610E Emergency disaster plan/Fire and Earthquake drill requirements with applicant. LPA observed the facility had the necessary posters in place (Complaint poster, LTCO poster, Rights to Council, etc). COVID-19 posters were also displayed in the main entrance, common areas and the bathrooms.

Component III is being waived.

This report will be submitted to the Centralized Application Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required.

Exit interview conducted with Applicant Nicolette Lake and a copy of report will be emailed.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2