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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601499
Report Date: 03/14/2023
Date Signed: 03/14/2023 11:31:40 AM


Document Has Been Signed on 03/14/2023 11:31 AM - 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:RELIEZ VALLEY CARE HOMEFACILITY NUMBER:
075601499
ADMINISTRATOR:MACDONALD, LEAHFACILITY TYPE:
740
ADDRESS:656 STERLING DRIVETELEPHONE:
(925) 370-6425
CITY:MARTINEZSTATE: CAZIP CODE:
94553
CAPACITY:6CENSUS: 4DATE:
03/14/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Dominador Lampano, CaregiverTIME COMPLETED:
11:40 AM
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On 03/14/2023 at 10:20 AM, Licensing Program Analysts (LPAs) L. Alexander and L. Hall arrived unannounced to conduct a POC Visit. LPAs met with Caregiver, Dominador Lampano and explained the purpose of the visit. Administrator, Leah MacDonald, arrived at 11:15 AM.

During visit LPAs inspected the garage where the Licensee had built a room. LPAs observed the room had been dismantled from the garage as pictures that was sent to CCLD on 3/1/2023 showed. LPAs cleared POC during visit.

No deficiencies cited during visit.

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: 03/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2023
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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