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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200623
Report Date: 06/07/2022
Date Signed: 06/07/2022 03:37:51 PM


Document Has Been Signed on 06/07/2022 03:37 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:KENSINGTON, THEFACILITY NUMBER:
079200623
ADMINISTRATOR:MICHELA CIANCIOSIFACILITY TYPE:
740
ADDRESS:1580 GEARY RDTELEPHONE:
(925) 943-1121
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94597
CAPACITY:200CENSUS: 157DATE:
06/07/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:14 PM
MET WITH:David Ayala, AdministratorTIME COMPLETED:
03:50 PM
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On 06/07/22 at 3:14PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit and met with administrator (ADM). LPA explained the purpose of the visit with ADM which was to amend the original reports dated 05/13/22 and re-issue citations past the 10 day period. ADM agreed to submit the proof of corrections on or before 06/27/22 to CCLD.

ADM agreed to destroy original complaint reports received 05/13/22 and replace them with the amended reports dated 06/07/22.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2022
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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