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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201138
Report Date: 10/02/2026
Date Signed: 10/05/2026 07:33:22 AM

Document Has Been Signed on 10/05/2026 07:33 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:ASSISTED GRACEFUL LIVINGFACILITY NUMBER:
019201138
ADMINISTRATOR/
DIRECTOR:		KHATU, MANALI SUHASFACILITY TYPE:
740
ADDRESS:3864 Princeton WayTELEPHONE:
(650) 440-9797
CITY:LivermoreSTATE: CAZIP CODE:
94550
CAPACITY: 6CENSUS: 6DATE:
10/02/2026
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Manali Khatu, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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On 10/02/2026 at 12:15 PM, Licensing Program Analyst (LPA) Ardalan Gharachorloo conducted a Health & Safety inspection as a result of Complaint #15-AS-20260930112646. LPA met with Administrator, Manali Khatu and explained the purpose of the visit. All members of the LLC were present during the visit.

LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. . The room temperature inside the facility was measured at 75 Degrees F. LPA observed lighting in all rooms are adequate. The hot water temperature in the residents’ shared bathroom was measured at 117.5 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.

LPA observed adequate supply of food and protein in the refrigerator. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 04/11/2026. Emergency Disaster Plan was reviewed during visit. First aid kit was observed to be complete.

LPA reviewed reviewed 6 resident files and 3 staff files. LPA reviewed a sample of 3 resident's medications.

***CONTINUE ON 809C***






Yvonne Flores-Larios
Ardalan Gharachorloo
DATE: 10/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/02/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ASSISTED GRACEFUL LIVING
FACILITY NUMBER: 019201138
VISIT DATE: 10/02/2026
NARRATIVE
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CONTINUE FROM 809***

The Following deficiency was observed during visit:

At approximately 10:47 AM, LPA observed multiple bags containing soiled/dirty resident clothing and bedding stored in the backyard near the laundry area. Administrator stated that laundry had not been completed due to a sewage backup affecting the laundry area.

The above deficiency was observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiency by POC date may result in additional Civil Penalties.

Exit interview conducted with Administrator. LIC809D, Appeal Rights and a copy of this report provided.
NAME OF LICENSING PROGRAM MANAGER: Yvonne Flores-Larios
NAME OF LICENSING PROGRAM ANALYST: Ardalan Gharachorloo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/05/2026 07:33 AM - It Cannot Be Edited


Created By: Ardalan Gharachorloo On 10/02/2026 at 11:28 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ASSISTED GRACEFUL LIVING
FACILITY NUMBER: 019201138

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/05/2026
Section Cited
CCR
87303(a)

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(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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Licensee shall repair the sewage backup and ensure the plumbing and laundry areas are maintained in a clean, safe, sanitary, and operable condition. Licensee shall submit proof of repair to CCLD by the POC due date.
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LPA observed multiple bags containing soiled resident clothing and bedding stored in the backyard near the laundry area. LPA observed that the facility was unable to complete residents’ laundry due to a sewage backup affecting the laundry area. This condition poses a potential health and safety risk to residents in care.
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Type B
10/09/2026
Section Cited
CCR87205(a)

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(a) The licensee, whether an individual or other entity, shall exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation in conformance with these regulations and the welfare of the individuals it serves.
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Licensee shall come up with a written plan of what the duties of each role. On record, Manali is the Administrator and submit it CCLD by POC date.
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Based on interviews and records reviewed, the Licensee failed to provide adequate supervision and oversight of the facility’s operations, which poses a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Ardalan Gharachorloo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2026


LIC809 (FAS) - (06/04)
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