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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200784
Report Date: 08/16/2023
Date Signed: 08/16/2023 11:40:34 AM


Document Has Been Signed on 08/16/2023 11:40 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:LAFAYETTE GARDENSFACILITY NUMBER:
079200784
ADMINISTRATOR:SAXENA, MEERANFACILITY TYPE:
740
ADDRESS:3486 MONROE AVENUETELEPHONE:
(408) 623-2859
CITY:LAFAYETTESTATE: CAZIP CODE:
94549
CAPACITY:6CENSUS: 6DATE:
08/16/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Meeran SaxenaTIME COMPLETED:
12:00 PM
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On this day, LPA Luisa Fontanilla conducted a case management related to complaint #15-AS-20230626112336 and met with Meeran Saxena.

During the course of investigation, LPA reviewed R1's admission agreement and interviewed R1's responsible person regarding refund. Based on the admission agreement, R1 moved to the facility on May 1, 2023. On June 7, 2023, R1's family notified the facility that R1 is not going back to the facility. R1 paid the facility two-months for rent which covered the first month May 1-June 1, 2023 and the 30-day notice to vacate.

Based on records review and interviews conducted, R1 is not due for any refund as indicated in the admission agreement.

No deficiency noted.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2023
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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