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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013419824
Report Date: 04/25/2022
Date Signed: 04/25/2022 09:45:57 AM


Document Has Been Signed on 04/25/2022 09:45 AM - 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:CHAVEZ, MARJORIEFACILITY NUMBER:
013419824
ADMINISTRATOR:CHAVEZ, MARJORIEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 680-6510
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:14CENSUS: 1DATE:
04/25/2022
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Majorie ChavezTIME COMPLETED:
10:00 AM
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On April 25, 2022 at 8:00 AM, Licensing Program Analyst (LPA) Elimika Woods met with licensee Majorie Chavez for an Unannounced Required 1 Year Inspection. LPA disclosed the purpose of the inspection and was granted entry into the facility by the licensee. LPA Woods forgot to Click on the Complete Inspection and had to continue the inspection.

There are no deficiencies cited. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee, Majorie Chavez.
SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Elimika WoodsTELEPHONE: (510) 622-2550
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2022
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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