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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601494
Report Date: 11/09/2022
Date Signed: 11/09/2022 06:23:26 PM


Document Has Been Signed on 11/09/2022 06:23 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:CARE HOME SWEET HOMEFACILITY NUMBER:
075601494
ADMINISTRATOR:CHONZOM, DICKEYFACILITY TYPE:
740
ADDRESS:316 LILAC CIRCLETELEPHONE:
(510) 799-1287
CITY:HERCULESSTATE: CAZIP CODE:
94547
CAPACITY:6CENSUS: 0DATE:
11/09/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
05:40 PM
MET WITH:Yanglin LiuTIME COMPLETED:
06:40 PM
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On 11/9/2022 at 5:40 PM Licensing Program Analysts (LPAs) C. Fowler and L. Alexander conducted a Case Management visit as a result of licensee requested closure of the facility. Upon arrival at 5:40 PM LPAs met with Yanglin Liu and spoke with the Licensee, Wenjie Yang, via phone.

On 10/18/2022, LPA received a letter from Licensee stating to changing the status of the facility to non-operation as of 10/21/2022. Facility will keep vacant until further notice. After speaking to the licensee via phone, she stated that she paid her license fees but will surrender her license today, 11/09/2022.

LPAs toured the entire facility with Yanglin Liu including kitchen, bathrooms, bedrooms, common areas, garage. LPAs confirmed all residents have moved out. Licensee surrendered her facility license during today's visit.

A forfeiture letter will be mailed to licensee at a later date. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2022
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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