<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200656
Report Date: 03/07/2024
Date Signed: 03/07/2024 05:11:51 PM

Document Has Been Signed on 03/07/2024 05:11 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:JAY MAHLER RECOVERY CENTERFACILITY NUMBER:
019200656
ADMINISTRATOR:GARCIA, DENISE GFACILITY TYPE:
772
ADDRESS:15430 FOOTHILL BOULEVARDTELEPHONE:
(510) 357-3562
CITY:SAN LEANDROSTATE: CAZIP CODE:
94578
CAPACITY: 16CENSUS: 11DATE:
03/07/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
05:00 AM
MET WITH:Clearnise Bullard/Administrator and
Michelle Mayberry-Porter/Regional Director 		TIME COMPLETED:
05:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
While at the facility investigating a complaint (Control # 15-AS-20240229112553), Clearnise Bullard, administrator, informed Licensing Program Analyst (LPA) Delmundo that the facility's Plan of Operation pertaining to the length of stay of the resident is changed from 30 days to 15 to 20 days as required by the County. The revision has not been submitted to the Department.

The Regional Director stated she'll submit a copy of the revision by next week,

Exit interview conducted and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1