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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011405349
Report Date: 10/30/2023
Date Signed: 10/30/2023 02:57:40 PM

Document Has Been Signed on 10/30/2023 02:57 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:
10/30/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Nathaniel Reed, AdministratorTIME COMPLETED:
03:00 PM
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On 10/30/23 at 2:35 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to deliver amended report for visit conducted on 10/16/23. LPA met with Administrator, Nathaniel Reed and explained the purpose of the visit.

Amended report, Non-compliance Conference Summary and LIC421D delivered to administrator.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2023
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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