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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200723
Report Date: 06/27/2024
Date Signed: 06/27/2024 06:22:16 PM

Document Has Been Signed on 06/27/2024 06:22 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/
DIRECTOR:		ALANNA SPENCERFACILITY TYPE:
772
ADDRESS:1480 159TH STREETTELEPHONE:
(510) 200-9134
CITY:SAN LEANDROSTATE: CAZIP CODE:
94578
CAPACITY: 14CENSUS: 5DATE:
06/27/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:45 PM
MET WITH:Kimberly Whitaker, Program DirectorTIME VISIT/
INSPECTION COMPLETED:
05:00 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 6/27/2024 at 3:45PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit in regards to law enforcement contact report received on 6/24/2024. LPA met with staff, Carolyn Curry and explained the purpose of the visit. Program Director, Kimberly Whitaker arrived an hour later.


LPA received report on 6/24/2024 which stated that client (C1) was not given weekend pass and was last at the facility on 6/21/2024.


LPA interviewed staff and obtained documents including C1's physician's report. LPA observed physician's report stated that C1 can leave the facility unassisted.


Exit interview conducted with Kimberly Whitaker. A copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2024
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