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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201405
Report Date: 08/06/2024
Date Signed: 08/06/2024 01:03:07 PM

Document Has Been Signed on 08/06/2024 01:03 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:EASTBAY VILLASFACILITY NUMBER:
079201405
ADMINISTRATOR/
DIRECTOR:		SURIAO, MARINAFACILITY TYPE:
740
ADDRESS:5302 CHEROKEE WAYTELEPHONE:
(925) 689-6551
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY: 6CENSUS: 0DATE:
08/06/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:19 PM
MET WITH:Marina Suriao, Applicant/AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:10 PM
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On 08/06/24 while at the facility for another reason, Licensing Program Analyst (LPA) D Panlilio conducted a component III presentation with administrator (ADM)/ applicant.

LPA discussed the common deficiencies that residential care facilities for the elderly are cited on, Title 22 regulations on infection control, physical plant, personnel requirements on clearances and associations, training, emergency/disaster/food requirements, etc. ADM agrees to comply with Title 22 regulations.

ADM was reminded of the statute that requires CCL to be notified within 5 business days of admitting their first resident. This notification may be done by phone, by mail, or by fax.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2024
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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