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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
019200670
Report Date:
08/23/2023
Date Signed:
08/28/2023 12:23:37 PM
Document Has Been Signed on
08/28/2023 12:23 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
OAKLAND ASC
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
ACAPULCO SENIOR CARE HOME
FACILITY NUMBER:
019200670
ADMINISTRATOR:
KA, NIN
FACILITY TYPE:
740
ADDRESS:
14160 ACAPULCO ROAD
TELEPHONE:
(510) 924-7457
CITY:
SAN LEANDRO
STATE:
CA
ZIP CODE:
94577
CAPACITY:
6
CENSUS:
DATE:
08/23/2023
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
10:00 AM
MET WITH:
TIME COMPLETED:
10:30 AM
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SUPERVISOR'S NAME:
Bennett Fong
TELEPHONE:
(510) -62-2621
LICENSING EVALUATOR NAME:
James Sampair
TELEPHONE:
(510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
08/23/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/23/2023
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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