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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201190
Report Date: 01/25/2023
Date Signed: 01/25/2023 11:21:53 AM

Document Has Been Signed on 01/25/2023 11:21 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:QUALITY CARE ADULT PROGRAM - 33RD STREETFACILITY NUMBER:
019201190
ADMINISTRATOR:MONTGOMERY, CHADFACILITY TYPE:
735
ADDRESS:624 33RD STREETTELEPHONE:
(510) 922-1936
CITY:OAKLANDSTATE: CAZIP CODE:
94609
CAPACITY: 4CENSUS: 0DATE:
01/25/2023
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Chad Montgomery and Jamese Victoria Walters, Applicants/AdministratorsTIME COMPLETED:
11:30 AM
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On 1/25/23 starting approximately at 10:30am, LPA C. Lin conducted a face to face Component III presentation. LPA met with applicants/administrators respectfully, Chad Montgomery and Jamese Victoria Walters.

LPA presented Component III PowerPoint and discussed the regulations embodied in the PowerPoint. LPA observed that the two participants gained knowledge about running and maintaining the facility in accordance with regulations.

Exit interview conducted with both applicants/administrators, and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE: DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/25/2023
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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