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Department of
SOCIAL SERVICES

Community Care Licensing


HOME CARE ORGANIZATION EVALUATION REPORT

Facility Number: 074700123
Report Date: 07/08/2022
Date Signed: 07/19/2022 03:20:12 PM

Document Has Been Signed on 07/19/2022 03:20 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

HOME CARE ORGANIZATION EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 744 P STREET, MS 09-14-90
SACRAMENTO, CA 95814
FACILITY NAME:ELDER FIRST LLCFACILITY NUMBER:
074700123
ADMINISTRATOR:CHRISTINE MARTINEZFACILITY TYPE:
300
ADDRESS:2917 SIMBA PLACETELEPHONE:
(510) 876-7877
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: CENSUS: DATE:
07/08/2022
Case Management - Biennial Required ContinuationUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:N/ATIME COMPLETED:
12:00 PM
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On 7/8/2022, an attempt was made to perform an unannounced inspection of Elder First LLC. A licensee or designee shall be continuously present during the Home Care Organization’s (HCO) business office hours. Any additional incomplete inspections may result in the issuance of civil penalties or possible license revocation. Please notify your assigned analyst of any changes to the HCO location or anticipated hours of operation.
LICENSING EVALUATOR NAME: Ramsey Chimienti
LICENSING EVALUATOR SIGNATURE: DATE: 07/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

HCS809 (FAS) - (06/04)
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