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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200311
Report Date: 06/17/2022
Date Signed: 06/17/2022 11:59:29 AM

Document Has Been Signed on 06/17/2022 11:59 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:THOMAS-ADAMS RESIDENTIAL CARE FACILITY, INC.FACILITY NUMBER:
019200311
ADMINISTRATOR:HAROLD THOMASFACILITY TYPE:
735
ADDRESS:5152-5158 FOOTHILL BLVD.TELEPHONE:
(510) 533-3470
CITY:OAKLANDSTATE: CAZIP CODE:
94601
CAPACITY: 32CENSUS: DATE:
06/17/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Barbara Cooper, Care StaffTIME COMPLETED:
12:00 PM
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On 6/17/22 at 11:45 a.m., Licensing Program Analyst (LPA) G. Clark arrived unannounced to deliver amended LIC 9099. LPA met with care staff Barbara Cooper and explained the purpose of the visit.

LPA needed to included more details then were in the original report dated 6/13/22.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE: DATE: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2022
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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