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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013414320
Report Date: 12/20/2019
Date Signed: 12/20/2019 11:54:56 AM

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 1102
OAKLAND, CA 94612
FACILITY NAME:AGNEW, DOROTHY & STEPHENS, CLEOTHAFACILITY NUMBER:
013414320
ADMINISTRATOR:AGNEW, DOROTHYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 614-9156
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY:14CENSUS: 5DATE:
12/20/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Dorothy AgnewTIME COMPLETED:
12:10 PM
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Licensing Program Analysts (LPAs) Junell Chen and Caroline Colson arrived for an unannounced case management inspection and met with Licensee Dorothy Agnew. Present for this inspection was fingerprint cleared assistant Abeer Nasser. The reason for this visit is to verify that the Type A deficiency cited on 12/17/19 during the annual random inspection is cleared. There are three infants and two preschoolers in care today. The facility is in ratio today.

All required licensing documents are posted and visible for public review.

This report shall remain on file for 3 years. A Notice of Site Visit was provided at time of inspection and must remain posted for 30 days. Exit interview conducted with Licensee. Copy of report and appeal rights provided.
SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Junell ChenTELEPHONE: (510) 622-4035
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2019
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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