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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201198
Report Date: 09/29/2022
Date Signed: 09/29/2022 12:32:39 PM

Document Has Been Signed on 09/29/2022 12:32 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:SOUTHWOOD SENIOR LIVING, LLCFACILITY NUMBER:
079201198
ADMINISTRATOR:VILLANUEVA, VELBAFACILITY TYPE:
740
ADDRESS:2073 SOUTHWOOD DRIVETELEPHONE:
(415) 509-1667
CITY:SAN PABLOSTATE: CAZIP CODE:
94806
CAPACITY: 4CENSUS: 1DATE:
09/29/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Israel Capuyan, AdministratorTIME COMPLETED:
11:50 AM
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On 09/29/2022 at 9:50 AM, Licensing Program Analyst (LPA) C. Fowler arrived unannounced to conduct a prelicensing inspection. LPA met with Administrator, Israell Capuyan and explained the purpose of the visit.

LPA toured facility including but not limited to 3 bedrooms, 2 bathrooms, kitchen, common areas and backyard. Bedrooms and living room was 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 70 degrees F and hot water temperature was maintained at 116 degrees F. First-aid kit was observed to be complete. Smoke detectors and carbon monoxide were operational. Fire extinguisher was last serviced on 5/4/2022.

Prior to licensure, the following shall be corrected, purchase locks and lock storage spaces located in the backyard and email photos to CCLD by 09/30/2022.

No issues noted during inspection. COMP III has been waived, Facility Administrator not available during visit. 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: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2022
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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