<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
013416017
Report Date:
04/04/2023
Date Signed:
04/04/2023 05:35:13 PM
Document Has Been Signed on
04/04/2023 05:35 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
CCLD Regional Office
,
1515 CLAY STREET, SUITE 1102
OAKLAND
,
CA
94612
FACILITY NAME:
SHELMIRE, DIANNA & PALMORE, MARK
FACILITY NUMBER:
013416017
ADMINISTRATOR:
SHELMIRE & PALMORE
FACILITY TYPE:
810
ADDRESS:
TELEPHONE:
(510) 569-2078
CITY:
OAKLAND
STATE:
CA
ZIP CODE:
94605
CAPACITY:
14
CENSUS:
0
DATE:
04/04/2023
TYPE OF VISIT:
Case Management - Incident
UNANNOUNCED
TIME BEGAN:
02:15 PM
MET WITH:
Dianna Shelmire
TIME COMPLETED:
05:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
LPA Lisa Dyer met with licensee Dianna Shelmire for a Case Management visit as a result of receiving an unusual incident report.
As a result of this visit, there were no deficiencies cited.
Exit interview conducted.
SUPERVISOR'S NAME:
Loretta Dyson
TELEPHONE:
(510) 695-0243
LICENSING EVALUATOR NAME:
Phyllis Dyer
TELEPHONE:
(510) 725-7006
LICENSING EVALUATOR SIGNATURE:
DATE:
04/04/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/04/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
1
of
1