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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601132
Report Date: 04/30/2024
Date Signed: 04/30/2024 12:50:53 PM


Document Has Been Signed on 04/30/2024 12:50 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:AT HOME ELDERLY CAREFACILITY NUMBER:
015601132
ADMINISTRATOR:DELUNA, MARIA LOURDES D.FACILITY TYPE:
740
ADDRESS:15734 VIA ESMONDTELEPHONE:
(510) 278-3906
CITY:SAN LORENZOSTATE: CAZIP CODE:
94580
CAPACITY:5CENSUS: 0DATE:
04/30/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Maria Lourdes Deluna/Licensee TIME COMPLETED:
12:55 PM
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On April 29, 2024, the Department received a correspondence. The licensee, Maria Lourdes Deluna surrendered the license and submitted it along with the correspondence.

On this day, April 30, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a final walk through. LPA spoke over the phone with licensee who arrived after about 10 minutes.

LPA walked around the facility inside and out and confirmed there was no residents at the facility. LPA observed a For Sale signage in the front yard. LPA informed the licensee that LPA will process the Forfeiture of License.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/30/2024
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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