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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201322
Report Date: 07/24/2024
Date Signed: 07/24/2024 03:57:45 PM

Document Has Been Signed on 07/24/2024 03:57 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:G & C RESIDENTIAL-74TH AVENUEFACILITY NUMBER:
019201322
ADMINISTRATOR/
DIRECTOR:		JOHN F COOLEYFACILITY TYPE:
735
ADDRESS:1661 74TH AVENUETELEPHONE:
(919) 960-1906
CITY:OAKLANDSTATE: CAZIP CODE:
94621
CAPACITY: 6CENSUS: 3DATE:
07/24/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:15 PM
MET WITH:John Cooley, AdministatorTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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On 7/24/24 at 3:15 PM, LPA Greg Clark conducted a face to face Component III presentation. LPA met with licensee and administrator, John Cooley.

LPA presented Component III power point and discussed the regulations embodied in the power point. LPA observed the participans gained knowledge about running and maintaining the facility in accordance with regulations.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE: DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2024
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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