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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
019200199
Report Date:
04/29/2022
Date Signed:
04/29/2022 02:33:20 PM
Document Has Been Signed on
04/29/2022 02:33 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:
FCSN EAST BAY ADULT DAY PROGRAM
FACILITY NUMBER:
019200199
ADMINISTRATOR:
AI-CHING "SYLVIA" YEH
FACILITY TYPE:
775
ADDRESS:
2300 PERALTA BLVD.
TELEPHONE:
(510) 739-6900
CITY:
FREMONT
STATE:
CA
ZIP CODE:
94536
CAPACITY:
105
CENSUS:
DATE:
04/29/2022
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
02:15 PM
MET WITH:
Vivian Largusa, Program Director
TIME COMPLETED:
02:40 PM
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On 04/29/22 at 2:15 p.m. Licensing Program Analyst (LPA) Greg Clark arrived unannounced to deliver amended findings from the original compliant investigation findings delivered on 4/06/22. LPA met with Vivian Largusa and explained the purpose of the visit.
SUPERVISORS NAME
:
Yvonne Flores-Larios
LICENSING EVALUATOR NAME
:
Gregory Clark
LICENSING EVALUATOR SIGNATURE
:
DATE:
04/29/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/29/2022
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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