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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201237
Report Date: 06/07/2023
Date Signed: 06/07/2023 01:03:25 PM

Document Has Been Signed on 06/07/2023 01:03 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:MARION HOUSEFACILITY NUMBER:
019201237
ADMINISTRATOR:NISHIMOTO, JONFACILITY TYPE:
735
ADDRESS:3781 MARION AVETELEPHONE:
(510) 261-6764
CITY:OAKLANDSTATE: CAZIP CODE:
94619
CAPACITY: 6CENSUS: 5DATE:
06/07/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Jon Nishimoto, AdministratorTIME COMPLETED:
01:15 PM
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On 6/7/2023 at 10:15AM, Licensing Program Analysts (LPAs) K. Nguyen arrived unannounced to conduct Pre-licensing Inspection. Upon arrival, LPAs met with Jon Nishimoto Administrator, and explained the purpose of the visit. The facility currently have 5 clients.

LPA toured facility including but not limited to 3 bedrooms, 1 and 1 half bathrooms, kitchen, common areas and backyard. Bedrooms and living rooms were equipped with the proper furniture. Bathrooms were equipped with grab bars and shower seat. Linens and hygiene supplies were observed inside a cabinet. There is sufficient lighting throughout facility. Room temperature was maintained at 69 degrees F and hot water temperature was maintained at 106 degrees F. First-aid kit was observed to be complete. Smoke detectors and carbon monoxide were operational. Fire extinguisher was last serviced on 02/2/2023.

No issues noted during inspection. LPAs observed that facility is ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed, and is subject to final approval by CAU. Additional requirements may still be required.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2023
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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