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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200239
Report Date: 12/22/2021
Date Signed: 12/22/2021 11:42:11 AM

Document Has Been Signed on 12/22/2021 11:42 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:RES SUCCESSFACILITY NUMBER:
079200239
ADMINISTRATOR:IAN BREMNERFACILITY TYPE:
775
ADDRESS:702 ALFRED NOBEL DR.TELEPHONE:
(925) 229-8228
CITY:HERCULESSTATE: CAZIP CODE:
94547
CAPACITY: 30CENSUS: 8DATE:
12/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Roshni Scott, Program ManagerTIME COMPLETED:
11:50 PM
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On 12/22/2021 at 10:45 AM, Licensing Program Analyst (LPA) C. Fowler arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Program Director, Roshni Scott and explained the purpose of the visit. Day program operates from 8:30 AM 2:30PM. There were 6 staff observed working with the 8 clients here today.

LPA toured facility with Roshni Scott Program Director including but not limited to, multiple activity areas, kitchen, bathrooms, office space. Clients bring their own lunches and snacks. Emergency supplies, including water were observed. Cleaning supplies are locked and inaccessible to clients. Medications are not handled/dispensed by this program. There are no bodies of water or fire safety hazards observed. Restrooms are maintained in safe and in sanitary operating condition.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/22/2021
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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