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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601469
Report Date: 10/24/2024
Date Signed: 10/24/2024 12:47:19 PM


Document Has Been Signed on 10/24/2024 12:47 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:LOVING HOME CAREFACILITY NUMBER:
015601469
ADMINISTRATOR:GOLDASSIO, STEPHANIEFACILITY TYPE:
740
ADDRESS:22270 PERALTA STREETTELEPHONE:
(510) 582-8839
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:5CENSUS: 0DATE:
10/24/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Matilde Machado/Licensee and
Stephanie Goldassio/Administrator 		TIME COMPLETED:
12:50 PM
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On September 30, 2024, Licensing Program Analyst (LPA) Delmundo received an email from Robert Goldassio, back-up administrator, stating that the facility decided to close it's door effective October 1, 2024. On October 2, 2024, Oakland Regional Office received the license, hospice waiver approval letter and a letter from Matilde Machado, licensee, requesting the cancellation of license.

At 12:10 p.m. on this day, October 24, 2024, LPA arrived to the facility unannounced and met with licensee and Stephanie Goldassio, administrator. LPA informed the reason for visit.

LPA toured the facility inside out with the administrator. LPA observed no evidence of resident needing care and supervision living in the home. LPA informed the licensee and administrator that the forfeiture of license will be processed, and LPA will have a copy of Forfeiture of License letter mailed out.

Exit interview conducted and 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: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2024
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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