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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073402173
Report Date: 02/04/2020
Date Signed: 02/07/2020 09:32:03 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:SIMS-CARR, KISAFACILITY NUMBER:
073402173
ADMINISTRATOR:SIMS-CARR, KISAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 222-2266
CITY:RICHMONDSTATE: CAZIP CODE:
94806
CAPACITY:14CENSUS: 6DATE:
02/04/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Kisa Sims-CarrTIME COMPLETED:
01:20 PM
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(This is the verbatim computer record of a handwritten report completed on site and signed by LPA and licensee)

Licensing Program Analyst (LPA) Paul Petersen met with licensee, Kisa Sims-Carr, for a case management site inspection regarding licensee's adult daughter, Lanisha Carr. LPA informed licensee of information regarding appeal process for licensee's daughter. Licensee will resubmit "Notice of Defense" document along with a letter to CCL Oakland c/o address and contact provided on the Notice of Defense document.

There were no deficiencies cited during this inspection. A copy of this report was provided for licensee.
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Paul PetersonTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2020
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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