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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201048
Report Date: 08/23/2024
Date Signed: 08/23/2024 10:55:37 AM

Document Has Been Signed on 08/23/2024 10:55 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:REM CALIFORNIA LLC - ASHLANDFACILITY NUMBER:
019201048
ADMINISTRATOR/
DIRECTOR:		DELLA BOUGHTONFACILITY TYPE:
775
ADDRESS:29800 MISSION BLVDTELEPHONE:
(510) 278-3937
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY: 60CENSUS: 24DATE:
08/23/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Della Boughton, AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:05 AM
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Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct a case management. LPA met with Administrator (AD), Della Boughton and informed the purpose of LPA's visit and requested documents.

LPA confirmed with AD the current contact information of the program, and informed AD about the past due of the licensing fee.

LPA requested to have an email confirmation confirmed that the overdue have been resolved by 8/30/24.

Exit interview conducted and a copy of this report is provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2024
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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