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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
019201380
Report Date:
10/25/2024
Date Signed:
10/25/2024 04:19:30 PM
Document Has Been Signed on
10/25/2024 04:19 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:
KINGDOM BUILDERS TRANSITIONAL HOUSING PROGRAM
FACILITY NUMBER:
019201380
ADMINISTRATOR/
DIRECTOR:
JENNINGS, KAREN
FACILITY TYPE:
772
ADDRESS:
7988 SUNKIST DRIVE
TELEPHONE:
(510) 575-9881
CITY:
OAKLAND
STATE:
CA
ZIP CODE:
94605
CAPACITY:
6
CENSUS:
0
DATE:
10/25/2024
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
03:50 PM
MET WITH:
LJ Jennings, Licensee
TIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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An announced Pre-licensing Comp III associated with Pre-Licensing Inspection done on 10/25/2024 at 3:50 PM was conducted by Licensing Program Analyst (LPA) K. Nguyen. Comp III was attended by LJ Jennings Applicant.
LPAs concluded Comp III.
No citation made during this visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME
:
Bennett Fong
LICENSING EVALUATOR NAME
:
Kelly Nguyen
LICENSING EVALUATOR SIGNATURE
:
DATE:
10/25/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/25/2024
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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