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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601277
Report Date: 11/04/2021
Date Signed: 11/04/2021 03:45:57 PM

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:BETHANY HOME CARE 2FACILITY NUMBER:
015601277
ADMINISTRATOR:LEONG, CYNTHIA C.FACILITY TYPE:
740
ADDRESS:9460 MOUNTAIN BLVD.TELEPHONE:
(510) 635-7882
CITY:OAKLANDSTATE: CAZIP CODE:
94605
CAPACITY:6CENSUS: 0DATE:
11/04/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:George Y Leong, LicenseeTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) C. Lin and Licensing Program Manager (LPM) Jeremy Fong conducted an unannounced visit for a separate issue and met with Licensee George Leong. LPA and LPM were informed that a closure notice had been submitted to CCL and the residents were safely transferred to other facilities on 9/15/21. A subsequent letter was provided to CCL asking that facility maintain its license through the end of 2021. LPA and LPM were informed by Licensee that he now wishes to surrender the license.

Starting at 3:00pm, LPA and LPM toured entire facility with Licensee including kitchen, bathrooms, bedrooms, common areas, backyard and garage. LPA and LPM confirmed all residents have moved out, no staff were present, and the interior was under renovation.

A forfeiture letter will be mailed to licensee. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021
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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