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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600386
Report Date: 12/17/2024
Date Signed: 12/17/2024 02:46:15 PM

Document Has Been Signed on 12/17/2024 02:46 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:HARTNELL HOME CAREFACILITY NUMBER:
015600386
ADMINISTRATOR/
DIRECTOR:		PURUGANAN,VICTORIA C.FACILITY TYPE:
740
ADDRESS:2041 HARTNELL STREETTELEPHONE:
(510) 489-7290
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 3DATE:
12/17/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Jezrael Pascual, Facility ManagerTIME VISIT/
INSPECTION COMPLETED:
02:50 PM
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
During an complaint investigation (15-AS-20241213161313) LPAs K. Nguyen and L. Alexander observed that facility do not have a minimum of one week non- perishables food supply. LPAs tried to contact Administrator, but was not able due to phone went to voicemail. ADM gave permission for Jezrael to sign the report.

LPAs requested Administrator to submit on weekly basic of groceries receipt and photo of all food supplies to CCLD starting from the week 12/23/24:

No deficiency were cited at this time.

Exit interview is conducted and a copy of this report is provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2024
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