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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011406176
Report Date: 03/24/2023
Date Signed: 03/24/2023 04:17:35 PM

Document Has Been Signed on 03/24/2023 04:17 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:CONNIE'S REST HAVENFACILITY NUMBER:
011406176
ADMINISTRATOR:ANN PRINGLEFACILITY TYPE:
735
ADDRESS:5751 WALNUT STREETTELEPHONE:
(510) 569-9028
CITY:OAKLANDSTATE: CAZIP CODE:
94605
CAPACITY: 8CENSUS: 3DATE:
03/24/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:10 PM
MET WITH:Abraham Pringle, Care staffTIME COMPLETED:
04:20 PM
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On 3/24/23 , Licensing Program Analyst (LPA) G. Clark conducted 1-Year Annual Required inspection. Due to technical issues LPA was not able to leave the report. LPA will sent report to facility once it has been retrieved. A copy of this report provided
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE: DATE: 03/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2023
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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