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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
073401548
Report Date:
05/12/2022
Date Signed:
05/12/2022 12:46:38 PM
Document Has Been Signed on
05/12/2022 12:46 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, SUITE 1102
OAKLAND
,
CA
94612
FACILITY NAME:
MCGRUDER, KIMBERLY
FACILITY NUMBER:
073401548
ADMINISTRATOR:
MCGRUDER, KIMBERLY
FACILITY TYPE:
810
ADDRESS:
TELEPHONE:
(925) 776-4466
CITY:
ANTIOCH
STATE:
CA
ZIP CODE:
94509
CAPACITY:
14
TOTAL ENROLLED CHILDREN:
14
CENSUS:
3
DATE:
05/12/2022
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
09:00 AM
MET WITH:
KIMBERLY MCGRUDER
TIME COMPLETED:
12:30 PM
NARRATIVE
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LICENSING PROGRAM ANALYST TASHA ALEXANDER MET WITH LICENSEE KIMBERLY MCGRUDER TO DELIVER AN EXEMPTION DENIAL NOTICE FOR AN ADULT LIVING IN THE HOME.
LPA DISCUSSED AND EXPLAINED THE CONTENTS OF THE LETTER WITH LICENSEE. A COPY OF THE LETTER HAS BEEN PROVIDED.
AN EXIT INTERVIEW WAS CONDUCTED
SUPERVISORS NAME
:
Loretta Dyson
LICENSING EVALUATOR NAME
:
Tasha Hackett-Alexander
LICENSING EVALUATOR SIGNATURE
:
DATE:
05/12/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/12/2022
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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