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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013419328
Report Date: 11/26/2019
Date Signed: 12/16/2019 10:35:11 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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:KIM, HEESOOKFACILITY NUMBER:
013419328
ADMINISTRATOR:KIM, HEESOOKFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 533-3922
CITY:OAKLANDSTATE: CAZIP CODE:
94606
CAPACITY:14CENSUS: 5DATE:
11/26/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Heesook KimTIME COMPLETED:
02:00 PM
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Case Management site visit was conducted by LPA Susan Neeson. Met with Heesook Kim and her husband. Visit began at 1:00 PM. The purpose of the visit is to deliver the report from 11/25/19.

Also, two deficiencies cited on 11/25/19 were cleared.

No deficiencies were observed.

This report was not delivered due to mechanical malfunction.

An exit interview was given.
SUPERVISOR'S NAME: Antranette RobinsonTELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Susan NeesonTELEPHONE: (510)622-2630
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2019
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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