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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200315
Report Date: 08/04/2022
Date Signed: 08/04/2022 01:53:03 PM


Document Has Been Signed on 08/04/2022 01:53 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, STE. 310
OAKLAND, CA 94612



FACILITY NAME:MONTESSORI SENIOR RESIDENTIAL CAREFACILITY NUMBER:
079200315
ADMINISTRATOR:PAMELA ZELL RIGGFACILITY TYPE:
740
ADDRESS:3431 BALFOUR ROADTELEPHONE:
(925) 516-2111
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:6CENSUS: 0DATE:
08/04/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Shaku Chhagan, Assistant Administrator TIME COMPLETED:
02:00 PM
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On 8/4/202,2 Licensing Program Analyst (LPA) L. Ibo conducted a Case Management visit as a result of licensee requested closure of the facility. LPA met with Assistant Administrator Shaku Chhagan.

On May 30, 2022, Licensee issued a proper 60 days notice to all residents and sent LPA a copy via email of notice. Property is under construction and plan to sell the property.

Starting at 1:20 PM, LPA toured entire facility with Assistant Administrator including kitchen, bathrooms, bedrooms, common areas and backyard. LPA confirmed all residents have moved out. Assistant Administrator surrendered facility license during today's visit.

A forfeiture letter will be mailed or email to licensee and Assistant Administrator at a later time. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2022
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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