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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200880
Report Date: 08/31/2023
Date Signed: 08/31/2023 03:52:29 PM

Document Has Been Signed on 08/31/2023 03:52 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:ARIZONA CARE HOMEFACILITY NUMBER:
019200880
ADMINISTRATOR:VALENCIA-GARCIA, LALLIEFACILITY TYPE:
735
ADDRESS:33051 ARIZONA STTELEPHONE:
(510) 489-2465
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 3DATE:
08/31/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Lallie Valencia-GarciaTIME COMPLETED:
04:00 PM
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On this day at around 1:45 pm, Licensing Program Analyst Luisa Fontanilla arrived unannounced to interview Staff 4 (S4) related to complaint 15-AS-20230818100718. LPA met with staff Rosanna Refulgente. Administrator arrived at the facility at a later time.

A copy of this report was provided to Administrator.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2023
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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