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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200717
Report Date: 09/13/2021
Date Signed: 09/13/2021 04:14:07 PM

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:BAY HARBOUR CARE HOMEFACILITY NUMBER:
019200717
ADMINISTRATOR:RIVAS, DANIELAFACILITY TYPE:
740
ADDRESS:510 CENTRAL AVETELEPHONE:
(510) 523-0113
CITY:ALAMEDASTATE: CAZIP CODE:
94501
CAPACITY:12CENSUS: 0DATE:
09/13/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:50 PM
MET WITH:Daniela Rivas, LicenseeTIME COMPLETED:
04:25 PM
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On 9/13/2021 at 3:50PM, Licensing Program Analysts (LPAs) G. Luk and L. Hall arrived unannounced to conduct a case management inspection regarding facility closure. LPAs met with licensee, Daniela Rivas.

LPAs toured facility including but not limited to bedrooms, bathrooms, kitchen, and outdoor areas. LPAs observed that no residents present during inspection. Licensee provided original license and letter of closure to LPAs.

LPAs will send forfeiture letter to licensee at a later time.

Exit interview conducted. A copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2021
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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