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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200723
Report Date: 08/16/2024
Date Signed: 08/16/2024 09:36:03 AM

Document Has Been Signed on 08/16/2024 09:36 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/
DIRECTOR:		ALANNA SPENCERFACILITY TYPE:
772
ADDRESS:1480 159TH STREETTELEPHONE:
(510) 200-9134
CITY:SAN LEANDROSTATE: CAZIP CODE:
94578
CAPACITY: 14CENSUS: 9DATE:
08/16/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Jonathan Haskins, Case Manager TIME VISIT/
INSPECTION COMPLETED:
09:45 AM
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An unannounced case management visit was conducted by Licensing Program Analysts (LPA) J. Clancy-Czuleger and P. Manalo. The purpose of this visit is to advise the licensee that a Non-Compliance Conference has been scheduled September 6, 2024 at 1:30 p.m. via zoom. The purpose of this conference is to discuss compliance issues that occurred regarding Complaint Number 15-AS-20231026151036.



A copy of the Non-Compliance letter was given to Jonathan Haskins Case Manager while conducting exit interview
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2024
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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