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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440602
Report Date: 06/20/2022
Date Signed: 06/20/2022 01:53:14 PM


Document Has Been Signed on 06/20/2022 01:53 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:GM RESIDENTIAL CARE HOMEFACILITY NUMBER:
011440602
ADMINISTRATOR:CHILIN, GRICELDA G.FACILITY TYPE:
740
ADDRESS:4924 OMAR STREETTELEPHONE:
(510) 226-0102
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY:6CENSUS: 0DATE:
06/20/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Administrator- CHILIN, GRICELDA GTIME COMPLETED:
02:00 PM
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On 6/20/2022 at 1:35PM, Licensing Program Analysts (LPAs) L. Fici and L. Ibo arrived to conduct a closure inspection. LPAs met with Administrator, CHILIN, GRICELDA G

LPAs toured entire facility with Administrator including kitchen, bathrooms, bedrooms, common areas, backyard. LPAs confirmed all residents have moved out. Last resident moved out last May 31, 2022.

No deficiency cited on this date.

Licensee/Administrator surrendered the license via mail in April 2022. A forfeiture letter will be mailed to licensee at a later time.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon FiciTELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2022
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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