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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200726
Report Date: 05/25/2022
Date Signed: 05/25/2022 12:37:13 PM


Document Has Been Signed on 05/25/2022 12:37 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:SUNRISE CARE HOME IIFACILITY NUMBER:
019200726
ADMINISTRATOR:TAYAG, NANCY RFACILITY TYPE:
740
ADDRESS:1435 VIA LUCASTELEPHONE:
(510) 398-8677
CITY:SAN LORENZOSTATE: CAZIP CODE:
94580
CAPACITY:6CENSUS: 6DATE:
05/25/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Nancy Tayag, AdministratorTIME COMPLETED:
12:50 PM
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On 5/25/2022 at 11:20 AM, Licensing Program Analysts (LPAs) L. Francisco and K. Nguyen arrived unannounced for a Case Management visit to deliver amended report from complaint visit (cn# 15-AS-20210909122733) on 11/03/2021. LPAs met with Administrator Nancy Tayag and explained the purpose of the visit.

Exit interview with Administrator and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2022
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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