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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201424
Report Date: 01/30/2025
Date Signed: 01/30/2025 09:11:49 AM

Document Has Been Signed on 01/30/2025 09:11 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:FOREVER CARE HOMES LLCFACILITY NUMBER:
019201424
ADMINISTRATOR/
DIRECTOR:		LACY, JAYNEFACILITY TYPE:
735
ADDRESS:418 WARDEN AVETELEPHONE:
(312) 342-5638
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY: 6CENSUS: 0DATE:
01/30/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Licensee, Jayne LacyTIME VISIT/
INSPECTION COMPLETED:
09:25 AM
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An announced Pre-licensing Comp III associated with Pre-Licensing Inspection done on 1/30/2025 at 9:00 AM was conducted by Licensing Program Analyst (LPA) A Gomez. Comp III was attended by Applicant, Jayne Lacy.

LPA conducted and concluded Comp III.

No citation made during this visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE: DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2025
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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