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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011405349
Report Date: 06/22/2023
Date Signed: 06/22/2023 02:25:50 PM

Document Has Been Signed on 06/22/2023 02:25 PM - 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. 310
OAKLAND, CA 94612
FACILITY NAME:PALM TREE RESIDENTIAL CARE HOME #2FACILITY NUMBER:
011405349
ADMINISTRATOR:BERTHA REEDFACILITY TYPE:
735
ADDRESS:2212 - EAST 19TH STREETTELEPHONE:
(510) 532-7785
CITY:OAKLANDSTATE: CAZIP CODE:
94606
CAPACITY: 11CENSUS: 5DATE:
06/22/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Nathaniel Reed, AdministratorTIME COMPLETED:
02:20 PM
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On 6/22/2023 starting at 1:45 PM, Licensing Program Analyst (LPA) Gregory Clark arrived unannounced to conduct a case management visit. LPA met with Nathaniel Reed, Administrator and explained the purpose of the visit.

LPA went to the facility to deliver an Immediate Exclusion letter. It was confirmed S1 was present at the facility. Immediate Exclusion letter was delivered to S1 and the administrator. LPA has advised the administrator to disassociate the individual from their roster and submit an updated LIC 500. LPA confirmed S1 left the facility.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE: DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/22/2023
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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