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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200038
Report Date: 10/03/2024
Date Signed: 10/03/2024 11:10:22 AM

Document Has Been Signed on 10/03/2024 11:10 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:WALLACE PLACE CARE HOMEFACILITY NUMBER:
019200038
ADMINISTRATOR/
DIRECTOR:		MARISSA RUBIOFACILITY TYPE:
735
ADDRESS:5469 WALLACE PLACETELEPHONE:
(408) 807-2467
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY: 6CENSUS: 4DATE:
10/03/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Marissa Rubio, LicenseeTIME VISIT/
INSPECTION COMPLETED:
11:20 AM
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On 10/03/2024 at 10:30 am Licensing Program Analysts (LPAs) L. Alexander and P. Manalo conducted an unannounced Case Management visit regarding P&I monies. LPAs met with Caregiver, Saniata Melencion and explained the purpose of the visit. Saniata phoned Licensee/Administrator, Marissa Rubio, to inform. Marissa arrived shortly after.

During the annual visit on 09/11/2024, Administrator did not have P&I Monies at the facility for C1 and C2. LPAs reviewed and counted the monies with Licensee/Administrator. Monies reviewed was $159.00 and $122.00 for C1 and C2 respectively.

No deficiencies issued during the visit.

Exit interview conducted and a copy of this report was provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2024
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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