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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200723
Report Date: 11/14/2023
Date Signed: 11/14/2023 03:57:53 PM

Document Has Been Signed on 11/14/2023 03:57 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
E BAY DELTA AC/SC, 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: 7DATE:
11/14/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Jacqueline Smith, Clinical Director
Anne Davis, Human Resources 		TIME COMPLETED:
04:15 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
On 11/14/2023 at 3:00 PM, Licensing Program Analysts (LPAs) P. Watson and K. Nguyen arrived unannounced to conduct a case management visit to confirm the removal of S1. LPAs spoke to Clinical Director, Jacqueline Smith, on the phone and explained the purpose of the visit. Jacqueline was unable to join the visit and allowed staff to sign.


LPAs have verified that S1 is not present, employed, or residing at the facility. Clinical Director stated that S1 last day employed was in September 2023, Clinical Director contacted HR to obtain the exact date but was unable to confirm while on the phone with LPAs. LPAs have advised the Clinical Director to disassociate the individual from their roster and submit an updated LIC 500.




Exit interview conducted and a copy of this report provided via email.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Paris Watson
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2023
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