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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
073405797
Report Date:
02/13/2020
Date Signed:
02/13/2020 03:56:39 PM
COMPREHENSIVE INSPECTION
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:
BLACKNELL-MILLS, ANTOINETTE
FACILITY NUMBER:
073405797
ADMINISTRATOR:
BLACKNELL-MILLS, ANTOINETT
FACILITY TYPE:
810
ADDRESS:
TELEPHONE:
(707) 333-9040
CITY:
RODEO
STATE:
CA
ZIP CODE:
94572
CAPACITY:
14
CENSUS:
DATE:
02/13/2020
TYPE OF VISIT:
Annual/Random
UNANNOUNCED
TIME BEGAN:
10:05 AM
MET WITH:
TIME COMPLETED:
10:30 AM
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SUPERVISOR'S NAME:
Sherelle Johnson
TELEPHONE:
(510) 622-2592
LICENSING EVALUATOR NAME:
Melissa Guirit
TELEPHONE:
(510) 622-2624
LICENSING EVALUATOR SIGNATURE:
DATE:
02/13/2020
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/13/2020
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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