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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
019200202
Report Date:
01/11/2024
Date Signed:
01/11/2024 02:05:40 PM
Document Has Been Signed on
01/11/2024 02:05 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:
MALAMA HOME
FACILITY NUMBER:
019200202
ADMINISTRATOR:
THELMA B. RUIZ
FACILITY TYPE:
735
ADDRESS:
4467 LISA DRIVE
TELEPHONE:
(510) 475-8052
CITY:
UNION CITY
STATE:
CA
ZIP CODE:
94587
CAPACITY:
4
CENSUS:
4
DATE:
01/11/2024
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
09:30 AM
MET WITH:
Arlene Ruiz
TIME COMPLETED:
10:15 AM
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On this day at around 9:30 am, LPA Luisa Fontanilla arrived unannounced to amend report previously issued on 12/28/2023. LPA met with Administrator Arlene Ruiz.
LPA provided Administrator a copy of the amended report.
SUPERVISORS NAME
:
Yvonne Flores-Larios
LICENSING EVALUATOR NAME
:
Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE
:
DATE:
01/11/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/11/2024
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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