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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200333
Report Date: 11/30/2022
Date Signed: 11/30/2022 09:50:03 AM

Document Has Been Signed on 11/30/2022 09:50 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:SAI NEWARK MANORFACILITY NUMBER:
019200333
ADMINISTRATOR:GRACE R. ACOSTAFACILITY TYPE:
735
ADDRESS:36603 DEBORAH STREETTELEPHONE:
(510) 739-1065
CITY:NEWARKSTATE: CAZIP CODE:
94560
CAPACITY: 6CENSUS: 6DATE:
11/30/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Venice Ayala- AdminisatratorTIME COMPLETED:
09:55 AM
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On 11/30/2022, at 9:25 AM, Licensing Program Analysts (LPAs) Liridon Fici and Catherine Lin conducted an unannounced case management visit to deliver an amended Lic421 Civil Penalty Assessment dated for 10/27/2022. LPAs met with Venice Ayala, administrator (ADM) and explained the purpose of the visit.

During visit, LPAs delivered the amended Lic421BG Civil Penalty Assessment dated 11/30/2022 and obtained original Lic421IM dated 10/27/2022.




Exit interview conducted with Administrator and copy of this report provide.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2022
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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