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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 01:20:22 PM
Document Has Been Signed on
06/07/2023 01:20 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 HOUSE
FACILITY NUMBER:
019201237
ADMINISTRATOR:
NISHIMOTO, JON
FACILITY TYPE:
735
ADDRESS:
3781 MARION AVE
TELEPHONE:
(510) 261-6764
CITY:
OAKLAND
STATE:
CA
ZIP CODE:
94619
CAPACITY:
6
CENSUS:
5
DATE:
06/07/2023
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
01:15 PM
MET WITH:
Jon Nishimoto Administrator,
TIME COMPLETED:
01:25 PM
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On 06/07/2023 at 1:15 pm Licensing Program Analysts (LPAs) K. Nguyen conducted an announced pre-licensing inspection with a Comp III and met with Jon Nishimoto - Administrator.
LPA and LPM discussed for Comp III to be waived because Jon Nishimoto has been the administrator since 2003. Comp III had been waived per Licensing Program Manager (LPM) J. Fong.
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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