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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201167
Report Date: 07/22/2022
Date Signed: 07/22/2022 04:44:41 PM


Document Has Been Signed on 07/22/2022 04:44 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:ELEGANCE AT DUBLINFACILITY NUMBER:
019201167
ADMINISTRATOR:COONS, JENNIFERFACILITY TYPE:
740
ADDRESS:7601 AMADOR VALLEY ROADTELEPHONE:
(360) 836-4604
CITY:DUBLINSTATE: CAZIP CODE:
94568
CAPACITY:80CENSUS: DATE:
07/22/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Jennifer Coons, Executive DirectorTIME COMPLETED:
04:31 PM
NARRATIVE
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On 7/22/2022 starting at 4:00 PM, Licensing Program Analysts (LPAs) K. Nguyen and L. Francisco conducted a face to face Component III presentation. LPAs conducted Component III with Jennifer Coons, Executive Director.

LPAs presented Component III power point and discussed the regulations embodied in the power point. LPAs observed participant gained knowledge about running and maintaining the facility in accordance with regulations.

Exit interview conducted and a copy of report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2022
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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