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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200311
Report Date: 08/08/2023
Date Signed: 08/08/2023 03:06:20 PM

Document Has Been Signed on 08/08/2023 03:06 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: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: 31DATE:
08/08/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Rosita Stevens, House ManagerTIME COMPLETED:
03:15 PM
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On 8/08/23 at 2:30 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to deliver amended report for the allegation that facility did not provide care and supervision resulting in a client AWOL. LPA met with Rosita Stevens, House Manager and explained the purpose of the visit.

Amended report delivered to the House Manager.

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: 08/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2023
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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