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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013422944
Report Date: 09/13/2021
Date Signed: 09/13/2021 08:52:01 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 STE 1102
OAKLAND, CA 94612
FACILITY NAME:AGARWAL, SHRUTIFACILITY NUMBER:
013422944
ADMINISTRATOR:SHRUTI AGARWALFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(518) 836-8473
CITY:LIVERMORESTATE: CAZIP CODE:
94551
CAPACITY:14CENSUS: DATE:
09/13/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Shruti AgarwalTIME COMPLETED:
09:00 AM
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On September 13, 2021 Licensing Program Analyst (LPA) Jaylena Miller conducted a Case Management Inspection to add an in-law suite located in the backyard on-limits. The in-law suite passed a fire clearance on 9/7/2021. LPA Miller conducted a health and safety inspection and is available to use as of 9/13/2021.

No deficiencies cited today. Exit interview conducted with Licensee and she was provided a copy of their appeal rights.

Notice of site visit was posted at the time of the inspection and must remain posted for 30 days.

A copy of this report shall be maintained for 3 years and available for public review upon request.
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Jaylena MillerTELEPHONE: (510) 292-8297
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2021
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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