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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200273
Report Date: 04/02/2024
Date Signed: 04/02/2024 11:16:02 AM

Document Has Been Signed on 04/02/2024 11:16 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:COLE VOCATIONAL SERVICES ALAMEDA COUNTY BMPFACILITY NUMBER:
019200273
ADMINISTRATOR:HAILU, LUFACILITY TYPE:
775
ADDRESS:1479 SALMON WAYTELEPHONE:
(510) 429-1919
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY: 45CENSUS: 16DATE:
04/02/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Pele Martin, Director TIME COMPLETED:
11:30 AM
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On today date at 10am, LPA K. Nguyen arrived at the facility unannounced spoke with Director Pele Martin and explained the purpose of the visit. LPA delivered an immediate exclusion letter from the department of social services for S1. LPA spoke with Director and confirmed that S1 is no longer working at the facility.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 04/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/02/2024
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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