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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
019201437
Report Date:
10/15/2024
Date Signed:
10/15/2024 02:23:29 PM
Document Has Been Signed on
10/15/2024 02:23 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:
CARMELITA CARE LLC
FACILITY NUMBER:
019201437
ADMINISTRATOR/
DIRECTOR:
TABION, RODERICK
FACILITY TYPE:
735
ADDRESS:
31832 KENNET STREET
TELEPHONE:
(510) 277-2335
CITY:
HAYWARD
STATE:
CA
ZIP CODE:
94544
CAPACITY:
6
CENSUS:
0
DATE:
10/15/2024
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:
Roderick Tabion/Applicant-Admininistrator
and Brenda Hyunh/Applicant
TIME VISIT/
INSPECTION COMPLETED:
02:35 PM
NARRATIVE
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An announced Pre-licensing Comp III associated with Pre-Licensing Inspection done on 10/15/2024 at 2:00 PM was conducted by Licensing Program Analysts (LPAs) K. Nguyen and P. Manalo. Comp III was attended by Roderick Tabion/Applicant-Admininistrator and Brenda Hyunh/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:
10/15/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/15/2024
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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