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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013414632
Report Date: 11/12/2019
Date Signed: 11/12/2019 11:28:20 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:PRINCIPLED ACADEMY, THEFACILITY NUMBER:
013414632
ADMINISTRATOR:FLORENDO, AURELIAFACILITY TYPE:
850
ADDRESS:2305 WASHINGTON AVENUETELEPHONE:
(510) 351-6400
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY:34CENSUS: 26DATE:
11/12/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Isaac DurstTIME COMPLETED:
11:30 AM
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LPA Dayna Collier met with Head of School Isaac Durst for a case management inspection as a result of receiving an unusual incident report.

As a result of the inspection, there were no deficiencies cited.

A SITE VISIT NOTICE WAS POSTED BY MR. DURST.
SUPERVISOR'S NAME: Diane PerezTELEPHONE: (510) 622-2590
LICENSING EVALUATOR NAME: Dayna CollierTELEPHONE: (510) 725-7021
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2019
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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