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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200723
Report Date: 10/27/2023
Date Signed: 10/27/2023 01:00:11 PM

Document Has Been Signed on 10/27/2023 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:KIMBILIOFACILITY NUMBER:
019200723
ADMINISTRATOR:ALANNA SPENCERFACILITY TYPE:
772
ADDRESS:1480 159TH STREETTELEPHONE:
(510) 200-9134
CITY:SAN LEANDROSTATE: CAZIP CODE:
94578
CAPACITY: 14CENSUS: 8DATE:
10/27/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Lanzo Walker Jr., House ManagerTIME COMPLETED:
01:10 PM
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On 10/27/23 at 12:55PM, Licensing Program Analyst (LPA) J. Clancy-Czuleger conducted a Health and Safety check as a result of the department receiving a priority 2 complaint.

During the health and safety check, LPA observed a total of 2 staff members and 8 residents at the facility. LPA toured facility with house manager, including but not limited to bedrooms, kitchen, bathroom, and common areas. Residents in care appear to be safe and there are no imminent health/safety concerns on today's date.

No deficiencies cited during the health and safety check. Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2023
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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