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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201233
Report Date: 07/25/2023
Date Signed: 07/25/2023 10:54:04 AM


Document Has Been Signed on 07/25/2023 10:54 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814



FACILITY NAME:CMA CARE HOME 1FACILITY NUMBER:
019201233
ADMINISTRATOR:ABOLENCIA, IMELDAFACILITY TYPE:
740
ADDRESS:4384 GIBRALTAR DRIVETELEPHONE:
(510) 673-8038
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY:6CENSUS: DATE:
07/25/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Imelda AbolenciaTIME COMPLETED:
10:45 AM
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Component II completion: Successful

Facility Type: RCFE
Application Type: Initial
Capacity: 6
Census (if any clients in care): none
COMP II Participants: Imelda Abolencia, applicant/administrator
Interview Method: Telephone interview

On July 25, 2023, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained.
SUPERVISOR'S NAME: Julia KimTELEPHONE: (916) 651-7848
LICENSING EVALUATOR NAME: Dianne RamosTELEPHONE: (916) 653-5973
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2023
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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