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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
019201108
Report Date:
02/24/2022
Date Signed:
02/24/2022 02:04:44 PM
Document Has Been Signed on
02/24/2022 02:04 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:
HEALTHY LIVING RESIDENTIAL CARE, INC.
FACILITY NUMBER:
019201108
ADMINISTRATOR:
BOOKER, JOSEFINA
FACILITY TYPE:
740
ADDRESS:
1179 VIA LUCAS
TELEPHONE:
(510) 397-0326
CITY:
SAN LORENZO
STATE:
CA
ZIP CODE:
94580
CAPACITY:
6
CENSUS:
5
DATE:
02/24/2022
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
01:20 PM
MET WITH:
Josefina Booker, Administrator
TIME COMPLETED:
02:10 PM
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On 02/24/2022 at 1:20 pm LPAs C. Fowler and L. Hall conducted a face to face Component III presentation LPAs met with administrator Josefina Booker.
LPAs presented Component III power point and discussed the regulations embodied in the power point. LPAs observed the participant gained knowledge about running and maintaining the facility in accordance with regulations.
Exit interview conducted with Josefina Booker and a copy of report provided.
SUPERVISOR'S NAME:
Bennett Fong
TELEPHONE:
(510) -62-2621
LICENSING EVALUATOR NAME:
Carol Fowler
TELEPHONE:
(510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE:
02/24/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/24/2022
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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