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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601501
Report Date: 06/01/2022
Date Signed: 06/01/2022 04:11:43 PM


Document Has Been Signed on 06/01/2022 04:11 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:LANDMARK VILLAFACILITY NUMBER:
015601501
ADMINISTRATOR:DIANE PEDERSONFACILITY TYPE:
740
ADDRESS:21000 MISSION BLVD.TELEPHONE:
(510) 276-2872
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:140CENSUS: 71DATE:
06/01/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH: Diane Pederson/Executive Director TIME COMPLETED:
04:15 PM
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While at the facility to deliver the findings for a complaint #15-AS-20200710153037), Executive Director Diane Pederson informed Licensing Program Analyst (LPA) Delmundo that they have completed the facility's Infection Control Plan that is due for submission this month of June. Copy of the Infection Control Plan provided to LPA on this same day, June 1, 2022.

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: 06/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2022
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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