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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601344
Report Date: 10/21/2021
Date Signed: 10/21/2021 01:39:50 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:JULIET'S CARE HOMEFACILITY NUMBER:
015601344
ADMINISTRATOR:BALLESTEROS, JULIETFACILITY TYPE:
740
ADDRESS:3305 HUDSON COURTTELEPHONE:
(925) 417-7301
CITY:PLEASANTONSTATE: CAZIP CODE:
94588
CAPACITY:6CENSUS: 0DATE:
10/21/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Juliet Ballesteros, LicenseeTIME COMPLETED:
12:45 PM
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On 10/21/2021 at 11:05AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Case Management inspection regarding facility closure. LPA met with licensee, Juliet Ballesteros.

LPA toured the facility with licensee and observed no residents were present during inspection. Licensee stated that 4 residents were relocated to other facilities. Last resident moved out of the facility on 8/31/2021. LPA obtained names of residents and their contact information.

LPA will send forfeiture letter to licensee at a later time.

No deficiencies were cited on this date.

Exit interview conducted. A copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021
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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