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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010209844
Report Date: 09/16/2019
Date Signed: 09/16/2019 04:04:29 PM

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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:BLUESKIES FOR CHILDREN - ELLEN SHERWOOD NURS SCHFACILITY NUMBER:
010209844
ADMINISTRATOR:HALE, LIISAFACILITY TYPE:
850
ADDRESS:3021 BROOKDALE AVENUETELEPHONE:
(510) 261-1077
CITY:OAKLANDSTATE: CAZIP CODE:
94602
CAPACITY:54CENSUS: 46DATE:
09/16/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:35 PM
MET WITH:Claire BainerTIME COMPLETED:
04:30 PM
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Licensing Program Analyst Caroline Colson met with Spencer Perry, administrator and Claire Bainer, administrator, at 3:35 PM for an unannounced case management inspection. The purpose of the inspection was to discuss who will be the new applicant for the facility. The facility wants to have a new director but they have a new applicant. The Board Resolution, Administration Organization and Designation of Facility Responsibility were discuss to ensure that the facility has all the required documents to submit to have the new director.
SUPERVISOR'S NAME: Ann RobinsonTELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Caroline ColsonTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2019
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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