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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
019201193
Report Date:
11/22/2022
Date Signed:
11/22/2022 11:34:34 AM
Document Has Been Signed on
11/22/2022 11:34 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
CCLD Regional Office
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
RACHELL'S FACILITY
FACILITY NUMBER:
019201193
ADMINISTRATOR:
EVANS, RACHELL
FACILITY TYPE:
735
ADDRESS:
33103 8TH STREET
TELEPHONE:
(510) 331-2598
CITY:
UNION CITY
STATE:
CA
ZIP CODE:
94587
CAPACITY:
4
CENSUS:
DATE:
11/22/2022
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
10:40 AM
MET WITH:
Rachell Evens, Licensee
TIME COMPLETED:
11:40 AM
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LPA conducted Component III with Licensee and Administrator during visit. LPA presented Component III Power Point and discussed the regulations embodied in the presentation.
No issues noted during inspection. LPA observed that facility is ready to be licensed. This report will be submitted to the Centralized Application Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required.
Exit interview conducted and a copy of this report will be emailed.
SUPERVISORS NAME
:
Harpreet Humpal
LICENSING EVALUATOR NAME
:
Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE
:
DATE:
11/22/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/22/2022
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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