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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200783
Report Date: 06/11/2021
Date Signed: 06/11/2021 04:18:17 PM

Document Has Been Signed on 06/11/2021 04:18 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:B. RUIZ CAREHOME 2FACILITY NUMBER:
079200783
ADMINISTRATOR:JAMIE RUIZFACILITY TYPE:
740
ADDRESS:30 MERGANSER CTTELEPHONE:
(925) 698-1207
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 6CENSUS: 6DATE:
06/11/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:50 PM
MET WITH:Jaime RuizTIME COMPLETED:
04:35 PM
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LPA arrived at the facility and met with Administrator Jaime Ruiz, LPA handed civil penalty report from case management conducted on 6/9/2021.
LIC809D was also updated, citation was cleared.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 06/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/11/2021
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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