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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
013421968
Report Date:
06/23/2022
Date Signed:
06/23/2022 10:40:46 AM
Document Has Been Signed on
06/23/2022 10:40 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:
MAHARJAN, BASANTI
FACILITY NUMBER:
013421968
ADMINISTRATOR:
MAHARJAN, BASANTI
FACILITY TYPE:
810
ADDRESS:
TELEPHONE:
(510) 282-6653
CITY:
HAYWARD
STATE:
CA
ZIP CODE:
94541
CAPACITY:
14
CENSUS:
11
DATE:
06/23/2022
TYPE OF VISIT:
Case Management - Annual Continuation
UNANNOUNCED
TIME BEGAN:
08:15 AM
MET WITH:
Basanti Maharjan
TIME COMPLETED:
10:45 AM
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LPA Woods forgot to push the Complete Inspection tool
SUPERVISOR'S NAME:
Chandra Charles
TELEPHONE:
(510) 286-0966
LICENSING EVALUATOR NAME:
Elimika Woods
TELEPHONE:
(510) 622-2550
LICENSING EVALUATOR SIGNATURE:
DATE:
06/23/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/23/2022
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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