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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 014700154
Report Date: 11/21/2024
Date Signed: 11/21/2024 10:59:47 AM

Document Has Been Signed on 11/21/2024 10:59 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

HOME CARE ORGANIZATION EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
HOME CARE SERVICES, 744 P STREET, MS 09-14-90
SACRAMENTO, CA 95814
FACILITY NAME:LIGHTHOUSE HOMECARE PROVIDERS, LLCFACILITY NUMBER:
014700154
ADMINISTRATOR/
DIRECTOR:		SHYAM JR., ROBERTFACILITY TYPE:
300
ADDRESS:1220 HOMESTEAD LNTELEPHONE:
(510) 786-8637
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY: CENSUS: DATE:
11/21/2024
Required - 2 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Licensee - Robert Shyam Jr.TIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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Home Care Services Branch (HCSB) Analyst, Todd Borcher, arrived at the business office of Robert Shyam Jr. for a Two-Year Licensing inspection on November 21, 2024. Upon arrival, the Analyst identified himself and was greeted by licensee Robert Shyam Jr. The proper posting of business hours and license was observed. The Analyst was then shown to an area where the review of personnel and administrative files could be performed. Upon completion of the file review the Analyst discussed the findings of the inspection with the licensee and informed the licensee that no discrepancies were found. A copy of the report was provided with appeal rights. Exit interview was conducted.
LICENSING EVALUATOR NAME: Todd Borcher
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

HCS809 (FAS) - (06/04)
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