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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
019201339
Report Date:
03/28/2024
Date Signed:
03/28/2024 04:04:20 PM
Document Has Been Signed on
03/28/2024 04:04 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:
HOLY ANGELS RESIDENTIAL FACILITY 2
FACILITY NUMBER:
019201339
ADMINISTRATOR:
RIVERA, ELENA H.
FACILITY TYPE:
735
ADDRESS:
25874 BEL AIRE DRIVE
TELEPHONE:
(510) 303-5317
CITY:
HAYWARD
STATE:
CA
ZIP CODE:
94542
CAPACITY:
6
CENSUS:
0
DATE:
03/28/2024
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
03:30 PM
MET WITH:
Elena Rivera, Administrator
TIME COMPLETED:
04:15 PM
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On 3/28/24 LPA Greg Clark conducted a face to face Component III presentation with licensee/administrator Elena Rivera.
LPA presented Component III power point and discussed the regulations embodied in the power point. LPA observed the participants gained knowledge about running and maintaining the facility in accordance with regulations.
Exit interview conducted with xxxx a copy provided.
SUPERVISORS NAME
:
Yvonne Flores-Larios
LICENSING EVALUATOR NAME
:
Gregory Clark
LICENSING EVALUATOR SIGNATURE
:
DATE:
03/28/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/28/2024
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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