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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200723
Report Date: 07/24/2023
Date Signed: 07/24/2023 11:42:49 AM

Document Has Been Signed on 07/24/2023 11:42 AM - 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:KIMBILIOFACILITY NUMBER:
019200723
ADMINISTRATOR:ALANNA SPENCERFACILITY TYPE:
772
ADDRESS:1480 159TH STREETTELEPHONE:
(510) 200-9134
CITY:SAN LEANDROSTATE: CAZIP CODE:
94578
CAPACITY: 14CENSUS: 10DATE:
07/24/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:06 AM
MET WITH: Alanna Spencer, Administrator.TIME COMPLETED:
11:45 AM
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On 07/24/2023 at 09:06 AM Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to conduct a Case Management. LPA met with Alanna Spencer, Administrator.

LPA discussed an incident report that was submitted on 05/23/23. The facility gave additional details for the situation stating that the resident was "fixing" their bike with a pocket knife and it slipped and sliced his arm. The facility addressed the medical situation and confiscated the knife. The facility also explained that they discussed with the client about not having the knifes and using proper tools.


Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE: DATE: 07/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2023
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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