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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073405375
Report Date: 11/25/2019
Date Signed: 12/26/2019 02:32:03 PM

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:MCCULLOUGH, KIMFACILITY NUMBER:
073405375
ADMINISTRATOR:MCCULLOUGH, KIMFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 374-9893
CITY:RICHMONDSTATE: CAZIP CODE:
94804
CAPACITY:14CENSUS: 6DATE:
11/25/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Kim McCulloughTIME COMPLETED:
04:15 PM
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An unannounced Case management site visit was conducted by LPA Susan Neeson. Met with Kim McCullough, Licensee. Visit began at #:00 PM. Purpose of the visit was to determine if deficiencies cited previously had been cleared. There are 4 school age children and two preschoolers present.

Two previous deficiencies were cleared. POC Cleared letter was produced.

REPORT WAS NOT ISSUED DURING VISIT DUE TO MECHANICAL MALFUNCTION.

No deficiencies were observed.

An exit interview was given.
SUPERVISOR'S NAME: Antranette RobinsonTELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Susan NeesonTELEPHONE: (510)622-2630
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2019
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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