<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200131
Report Date: 12/20/2021
Date Signed: 12/20/2021 04:01:31 PM

Document Has Been Signed on 12/20/2021 04:01 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:IRAAS RESIDENTIAL CAREFACILITY NUMBER:
019200131
ADMINISTRATOR:MOMO R. DUOAFACILITY TYPE:
735
ADDRESS:1503 VIRGINIA STREETTELEPHONE:
(510) 969-5107
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY: 6CENSUS: 6DATE:
12/20/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Emeka Aniche, StaffTIME COMPLETED:
04:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 12/20/2021, Licensing Program Analysts (LPAs) C. Lin and G. Luk arrived unannounced visit to deliver the amended report dated on 10/8/2021. LPAs met with the staff Emeka Aniche and explained the purpose of the visit. Administrator was not on site and authorized staff Emeka sign on the report.

During visit, LPAs deliver the amended reports dated 10/8/2021, and obtained original reports dated 10/8/2021.

Also, LPAs reviewed and obtained 6 residents' individual program plan (IPP).

Exit interview conducted and copy of the report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1