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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601368
Report Date: 05/09/2024
Date Signed: 05/09/2024 10:29:03 AM


Document Has Been Signed on 05/09/2024 10:29 AM - 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:AGEWAY BOARDING CAREFACILITY NUMBER:
015601368
ADMINISTRATOR:DAYEH, VICTORIA & ANAFACILITY TYPE:
740
ADDRESS:2716 MEADOWLARK DRIVETELEPHONE:
(510) 475-8869
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:6CENSUS: 0DATE:
05/09/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Mihael Dayeh, LicenseeTIME COMPLETED:
10:45 AM
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On 05/09/24 at 9:30AM, Licensing Program Analyst (LPA) K. Nguyen met with Licensee who stated that RCFE facility Ages Ways Boarding Care has been closed since May 1, 2024. The facility closure was communicated to CCLD on March 14, 2024 (see 812s regarding facility closure). LPA observed that there are no clients, and the facility is empty.

Licensee stated this facility will be sold on May 14, 2024. LPA obtained the following documents from Licensee:

1. Letter request for closure.


2. Original License
3. Names of 2 clients which included in the formal email that was sent to CCLD, also names of the facilities to where the 2 clients were relocated, and the facility addresses and contact information.

Exit interview is conducted and a copy of this report is provided via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2024
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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