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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013419574
Report Date: 05/04/2022
Date Signed: 05/04/2022 04:57:53 PM


Document Has Been Signed on 05/04/2022 04:57 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 STE 1102
OAKLAND, CA 94612



FACILITY NAME:ALCORN-FERNANDEZ, LYNDAFACILITY NUMBER:
013419574
ADMINISTRATOR:ALCORN-FERNANDEZ, LYNDAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 396-2686
CITY:NEWARKSTATE: CAZIP CODE:
94560
CAPACITY:14CENSUS: 0DATE:
05/04/2022
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
04:46 PM
MET WITH:Robert FernandezTIME COMPLETED:
05:00 PM
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On 5/4/2022, Licensing Program Analyst (LPA) Jonathan Williams arrived to the facility unannounced for the purposes of delivering an amended report. LPA was met by Licensee's spouse. Licensee was not present at the facility and zero children were in care at the time of this visit.

LPA discussed amended report to Licensee's spouse and delivered copy. LPA spoke to Licensee over the phone to discuss amended report. Licensee stated to LPA over the phone that facility was closed on today's date.

Exit interview conducted. Notice of site visit given.
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 622-2602
LICENSING EVALUATOR NAME: Jonathan WilliamsTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2022
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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