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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
019200331
Report Date:
11/14/2024
Date Signed:
11/14/2024 09:03:56 AM
Document Has Been Signed on
11/14/2024 09:03 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:
COVENTRY CARE HOME
FACILITY NUMBER:
019200331
ADMINISTRATOR/
DIRECTOR:
MARIDEL Q. CORTEZ
FACILITY TYPE:
735
ADDRESS:
4284 COVENTRY WAY
TELEPHONE:
(510) 972-0861
CITY:
UNION CITY
STATE:
CA
ZIP CODE:
94587
CAPACITY:
6
CENSUS:
3
DATE:
11/14/2024
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:
Ricardo Cortez
TIME VISIT/
INSPECTION COMPLETED:
09:15 AM
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On this day at around 8:50 am, LPAs L. Fontanilla and P. Manalo arrived unannounced to amend report previously issued on 9/26/2024 and met with Ricardo Cortez.
LPAs provided Cortez a copy of the amended report.
SUPERVISORS NAME
:
Yvonne Flores-Larios
LICENSING EVALUATOR NAME
:
Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE
:
DATE:
11/14/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/14/2024
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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