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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201433
Report Date: 10/10/2024
Date Signed: 10/10/2024 03:45:19 PM

Document Has Been Signed on 10/10/2024 03:45 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:GRAND LAKE VISTAFACILITY NUMBER:
019201433
ADMINISTRATOR/
DIRECTOR:		KOO, HASMINFACILITY TYPE:
740
ADDRESS:365 STATEN AVENUETELEPHONE:
(408) 202-2236
CITY:OAKLANDSTATE: CAZIP CODE:
94610
CAPACITY: 15CENSUS: 13DATE:
10/10/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Hasmin Koo, Administrator/ApplicantTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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On 10/10/2024 at 1:30PM, Licensing Program Analysts (LPAs) G. Luk and D. Doidge conducted a face to face Component III presentation. LPAs met with Administrator, Hasmin Koo.

LPAs presented Component III power point and discussed the regulations embodied in the presentation. LPAs observed Administrator gained knowledge about running and maintaining the facility in accordance with Title 22 regulations.

LPAs concluded Component III.

Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2024
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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