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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200881
Report Date: 09/01/2022
Date Signed: 09/01/2022 11:55:47 AM


Document Has Been Signed on 09/01/2022 11:55 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:A BLISSFUL RETREAT, LLC-WILSONFACILITY NUMBER:
079200881
ADMINISTRATOR:OSMAN, SUMAIYAFACILITY TYPE:
740
ADDRESS:4248 WILSON LANETELEPHONE:
(925) 375-1581
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY:6CENSUS: 6DATE:
09/01/2022
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Sumaiya Osman,
Administrator		TIME COMPLETED:
12:20 PM
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On 09/01/2022 at 11:30am Licensing Program Analysts (LPAs) C. Fowler and P. Watson conducted an unannounced Case Management visit regarding an amendment of an annual visit . LPAs met with Administrator Sumaiya Osman and explained the purpose of the visit.

On 8/18/2022 LPA Carol Fowler did conduct an unannounced visit at this facility, however a report was generated under another facility in error. LPA generated this report on 8/19/2022 and returned to facility to have signed and issues on 9/01/2022. The visit was conducted on 8/18/2022 at 3:10pm.

No deficiencies issued during the visit.

Exit interview conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2022
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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