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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 03:44:52 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:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:George Y. Leong, LicenseeTIME COMPLETED:
04:00 PM
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On 11/4/2021 starting at 3:00 PM, Licensing Program Analyst (LPA) Catherine Lin and Licensing Program Manager (LPM) Jeremy Fong arrived unannounced to conduct Infection Control Inspection. LPA and LPM met with Licensee George Leong and explained the purpose of the visit.

Upon entry, LPA and LPM observed that facility was under renovation. There has no resident in care at the facility during visit. Licensee stated that the last resident was moved out the facility on 9/15/2021. Licensee had submitted a letter to inform CCL for planing of closure dated on 8/24/2021.

During visit, Licensee decided to close the facility and surrender the facility license.

No deficiency cited during visit. 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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