<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600144
Report Date: 05/03/2023
Date Signed: 05/03/2023 10:18:29 AM

Document Has Been Signed on 05/03/2023 10:18 AM - 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:HODGES RESIDENTIAL FACILITYFACILITY NUMBER:
015600144
ADMINISTRATOR:HODGES, A., C., & T.FACILITY TYPE:
735
ADDRESS:3320 LOMA VISTA WAYTELEPHONE:
(510) 536-0998
CITY:OAKLANDSTATE: CAZIP CODE:
94619
CAPACITY: 6CENSUS: 5DATE:
05/03/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Demauriee Ingraham, Direct Support Professional TIME COMPLETED:
10:25 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 5/3/2023 at 10:00AM, Licensing Program Analyst (LPA) K. Nguyen conducted an unannounced Case Management visit to deliver an amended complaint # 15-AS-20230217142619. LPA met with direct support professional (DSP) Demauriee Ingraham and explained the purpose of the visit. Administrator Anthony Hodges was not available at the moment. Administrator gave verbal permission for DSP to sign the report.

No deficiencies issued during the visit.

Exit interview conducted and a copy of this report was provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1