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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
019201259
Report Date:
07/27/2023
Date Signed:
07/27/2023 04:33:24 PM
Document Has Been Signed on
07/27/2023 04:33 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:
HEAVENLY CARE HOME
FACILITY NUMBER:
019201259
ADMINISTRATOR:
ABBASI, SHAHID
FACILITY TYPE:
740
ADDRESS:
36857 WALNUT ST.
TELEPHONE:
(925) 963-4081
CITY:
NEWARK
STATE:
CA
ZIP CODE:
94560
CAPACITY:
6
CENSUS:
0
DATE:
07/27/2023
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
04:00 PM
MET WITH:
Shahid Abbasi, Licensee/Applicant
TIME COMPLETED:
04:45 PM
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LPA Luisa Fontanilla conducted a case management to discuss Component lll with Licensee/Applicant.
LPA went over with Licensee Component lll Powerpoint presentation. LPA provided applicant CCL and LPA contact information.
A copy of this report was provided to applicant.
SUPERVISORS NAME
:
Yvonne Flores-Larios
LICENSING EVALUATOR NAME
:
Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE
:
DATE:
07/27/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/27/2023
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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