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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200510
Report Date: 08/26/2021
Date Signed: 08/26/2021 01:00:28 PM

Document Has Been Signed on 08/26/2021 01:00 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:CNS COURTYARD #122FACILITY NUMBER:
019200510
ADMINISTRATOR:STACEY MAGDEFRAUFACILITY TYPE:
735
ADDRESS:1465 65TH STREET, #122TELEPHONE:
(925) 719-5580
CITY:EMERYVILLESTATE: CAZIP CODE:
94608
CAPACITY: 2CENSUS: 1DATE:
08/26/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Stacey Madefrau, AdministratorTIME COMPLETED:
01:20 PM
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On 8/26/2021 starting at 12:00pm, Licensing Program Analysts (LPAs) L. Francisco and C. Lin arrived unannounced to conduct Case Management concurrently with Infection Control Inspection. LPAs met with Administrator, Stacey Magdefrau.

During the visit, facility's program plan was in question. However, LPAs were unable to verify program plan at facility. LPAs will review facility's program plan on file and will contact Administrator if additional information is required.

No deficiencies cited during visit and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Lizette Francisco
LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2021
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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