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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200922
Report Date: 07/30/2020
Date Signed: 07/30/2020 02:04:28 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 744 P STREET, MS 8-3-91
SACRAMENTO, CA 95814
FACILITY NAME:CASA SANDOVALFACILITY NUMBER:
019200922
ADMINISTRATOR:ROSANA FRIASFACILITY TYPE:
740
ADDRESS:1200 RUSSELL WAYTELEPHONE:
(510) 727-1700
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:99CENSUS: DATE:
07/30/2020
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:59 PM
MET WITH:TIME COMPLETED:
02:02 PM
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COMP II by CAB successfully completed

Facility Type: CHOW

Method: Telephone call with CAB
COMP II Participants: Ken Jaeger, CEO; Shannon Betker, analyst.

Applicant participated in COMP II at CAB via telephone call with analyst at CAB. Identification of the applicant and administrator was verified by confirming date of birth. During COMP II, applicant confirmed the understanding of Title 22. Component II was successfully completed. Applicant and administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
Administrator responsibilities
SUPERVISOR'S NAME: Jude De La ConcepcionTELEPHONE: (916) 651-7841
LICENSING EVALUATOR NAME: Shannon BetkerTELEPHONE: (916) 651-3018
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2020
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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