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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201138
Report Date: 03/28/2022
Date Signed: 03/28/2022 12:06:11 PM


Document Has Been Signed on 03/28/2022 12:06 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:ASSISTED GRACEFUL LIVINGFACILITY NUMBER:
019201138
ADMINISTRATOR:KHATU, MANALI SUHASFACILITY TYPE:
740
ADDRESS:3864 PRINCETON WAYTELEPHONE:
(650) 440-9797
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY:6CENSUS: 0DATE:
03/28/2022
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Manali Khatu, AdministratorTIME COMPLETED:
12:15 PM
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LPAs L. Hall and C. Fowler conducted a face to face Component III presentation on 03/28/2022 starting at 11:15am. LPAs met with Administrator, Manali Khatu.

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 and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2022
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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