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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200784
Report Date: 08/22/2023
Date Signed: 08/22/2023 11:09:35 AM


Document Has Been Signed on 08/22/2023 11:09 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:
08/22/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Erlinda MuletaTIME COMPLETED:
11:15 AM
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On this at around 10:10 am, LPA Luisa Fontanilla conducted a case management visit to amend report previously issued on 8/16/2023. LPA was met by staff Erlinda Muleta . LPA spoke with Meeran over the phone and she authorized staff to sign the report.

A copy of this report was provided to Muleta.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2023
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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