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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
073409255
Report Date:
05/30/2024
Date Signed:
05/30/2024 01:39:41 PM
Document Has Been Signed on
05/30/2024 01:39 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:
PERUMAL, SHEELA
FACILITY NUMBER:
073409255
ADMINISTRATOR/
DIRECTOR:
PERUMAL, SHEELA
FACILITY TYPE:
810
ADDRESS:
TELEPHONE:
(408) 315-0321
CITY:
BRENTWOOD
STATE:
CA
ZIP CODE:
94513
CAPACITY:
14
TOTAL ENROLLED CHILDREN:
4
CENSUS:
3
DATE:
05/30/2024
TYPE OF VISIT:
Case Management - Incident
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:
Sheela Perumal
TIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Cherie Acosta conducted an unannounced visit in regards to a self reported incident. LPA met with Sheela Perumal.
Licensee self reported that a child was injured while in care. Community Care Licensing Investigation Branch conducted an investigation in regards to the reported injury.
There are no citations issued as a result of the investigation.
Notice of Site Visit was provided and must be posted for 30 days.
Exit interview and report reviewed with Sheela Perumal.
SUPERVISORS NAME
:
Sherelle Johnson
LICENSING EVALUATOR NAME
:
Cherie Acosta
LICENSING EVALUATOR SIGNATURE
:
DATE:
05/30/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/30/2024
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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