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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
013423969
Report Date:
06/14/2024
Date Signed:
06/14/2024 02:02:31 PM
Document Has Been Signed on
06/14/2024 02:02 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, SUITE 1102
OAKLAND
,
CA
94612
FACILITY NAME:
SMITH, ADRIENA
FACILITY NUMBER:
013423969
ADMINISTRATOR/
DIRECTOR:
FACILITY TYPE:
810
ADDRESS:
TELEPHONE:
CITY:
STATE:
ZIP CODE:
CAPACITY:
8
TOTAL ENROLLED CHILDREN:
8
CENSUS:
0
DATE:
06/14/2024
TYPE OF VISIT:
Prelicensing
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
01:34 PM
MET WITH:
Adriena Smith
TIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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Please see LIC 809 and LIC809C for prelicensing (Change of location) visit report conducted on 6/14/2024.
SUPERVISORS NAME
:
Sherelle Johnson
LICENSING EVALUATOR NAME
:
Diana Campos
LICENSING EVALUATOR SIGNATURE
:
DATE:
06/14/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/14/2024
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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