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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201333
Report Date: 04/05/2024
Date Signed: 04/05/2024 01:41:33 PM

Document Has Been Signed on 04/05/2024 01:41 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:BLOCH CARE CA LLCFACILITY NUMBER:
019201333
ADMINISTRATOR/
DIRECTOR:		HAGGERTY, KIESHAFACILITY TYPE:
775
ADDRESS:2829 MIDDLEFIELD AVETELEPHONE:
(510) 770-0716
CITY:FREMONTSTATE: CAZIP CODE:
94539
CAPACITY: 6CENSUS: 0DATE:
04/05/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:David Bloch, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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On 4/05/24 at 12:45PM, Licensing Program Analyst (LPA) Greg Clark arrived announced to conduct pre-licensing inspection. LPA met with Administrator, David Bloch and explained the purpose of the visit. The facility currently has no clients.

LPA toured facility including but not limited to activity rooms, bathrooms, kitchen, common areas and backyard. There is sufficient lighting throughout facility. Room temperature was maintained at 70 degrees F and hot water temperature was maintained at 117.8 degrees F. Smoke detectors and carbon monoxide were operational.

Prior to licensure, the following shall be corrected: lock toxins and sharps, clean debris in front yard, secure hot tub and purchase first aid kit.

LPA will return at a later date to ensure compliance.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE: DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/05/2024
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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