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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201108
Report Date: 08/02/2023
Date Signed: 08/02/2023 12:23:39 PM


Document Has Been Signed on 08/02/2023 12:23 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:NERI, MAXFACILITY TYPE:
740
ADDRESS:1179 VIA LUCASTELEPHONE:
(510) 397-0326
CITY:SAN LORENZOSTATE: CAZIP CODE:
94580
CAPACITY:6CENSUS: 0DATE:
08/02/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Josefina Booker, LicenseeTIME COMPLETED:
12:30 PM
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On 8/02/23 at 11:30 a.m., Licensing Program Analyst (LPA) Greg Clark conducted a Case Management visit as a result of licensee informing LPA that she is closing the facility. Upon arrival at 11:30 a.m., LPA met with Licensee, Josefina Booker.

On 6/15/23 Licensee issued a proper 30 day notice to all four residents. LPA obtained a copy of R1's eviction letter and placement information for R1, R2, R3 and R4.

Starting at 12:15 p.m., LPA toured entire facility with Licensee including kitchen, bathrooms, bedrooms, common areas, backyard and garage. LPA confirmed all residents have moved out. Licensee surrendered her facility license during today's visit.

A forfeiture letter will be mailed to licensee at a later time. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory ClarkTELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2023
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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