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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200416
Report Date: 01/09/2023
Date Signed: 01/09/2023 03:23:06 PM

Document Has Been Signed on 01/09/2023 03:23 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:CNS COURTYARD #172FACILITY NUMBER:
019200416
ADMINISTRATOR:ROSCOE, ALEXANDRA RFACILITY TYPE:
735
ADDRESS:1465 65TH STREET, #172TELEPHONE:
(510) 601-7172
CITY:EMERYVILLESTATE: CAZIP CODE:
94608
CAPACITY: 2CENSUS: 2DATE:
01/09/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:ALEXANDRA ROSCOE, AdministratorTIME COMPLETED:
03:30 PM
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On 1/9/2023, Licensing Program Analyst (LPA) C. Lin arrived unannounced visit to deliver the amended report dated on 1/6/2023. LPA met with the Administrator and explained the purpose of the visit.

During visit, LPA delivered the amended report dated 1/9/2023, and obtained original report dated 1/6/2023.

Exit interview conducted and copy of the report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2023
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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