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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201338
Report Date: 03/06/2024
Date Signed: 03/06/2024 02:52:42 PM


Document Has Been Signed on 03/06/2024 02:52 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:MOONRAKER VILLA SENIOR CARE 2FACILITY NUMBER:
019201338
ADMINISTRATOR:AKAOSUGI, YONGFACILITY TYPE:
740
ADDRESS:22052 MAIN STREETTELEPHONE:
(510) 776-6084
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:6CENSUS: 0DATE:
03/06/2024
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Yong Akaosugi/Applicant-administrator.TIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Alicia Delmundo conducted an announced Component III Training via Teams Meeting with another LPA. LPA Tonica Syess-Gibson. Component III was attended by Yong Akaosugi, applicant-admininistrator.

LPA Delmundo presented the training via Power Point presentation, and had a discussion with the applicant.

Exit interview conducted and copy of this report provided at the conclusion of the training.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2024
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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