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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010215269
Report Date: 05/10/2023
Date Signed: 05/10/2023 03:00:12 PM


Document Has Been Signed on 05/10/2023 03:00 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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612



FACILITY NAME:O'BRIEN, SUSANFACILITY NUMBER:
010215269
ADMINISTRATOR:O'BRIEN, SUSANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 581-4727
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:14CENSUS: 0DATE:
05/10/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Susan O'BrienTIME COMPLETED:
03:15 PM
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On May 10, 2023 at 1:45 PM Licensing Program Analyst Elimika Woods conducted a case management visit for Susan O'Brien. LPA Woods was initially going to conduct a 1 Year Required inspection but the licensee said midway through the inspection that she change her mind and wishes to go inactive.

LPA Woods provided licensee the form LIC 9211 to go inactive status.

Licensee was reminded that the inactive status is an annual time frame basis, and that if she wishes to continue stay inactive she will need to notify RO and send another LIC 9211.

Exit interview conducted with licensee, Susan O'Brien and a copy of report was given to the licensee.
SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Elimika WoodsTELEPHONE: (510) 622-2550
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2023
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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