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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200976
Report Date: 11/12/2020
Date Signed: 11/12/2020 12:29:36 PM

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:JANGA CARE HOMEFACILITY NUMBER:
079200976
ADMINISTRATOR:KOLLIE, COMFORT K.FACILITY TYPE:
740
ADDRESS:3601 GENTRYTOWN DRTELEPHONE:
(510) 677-3734
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:6CENSUS: 0DATE:
11/12/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Comfort Kollie, Administrator/ApplicantTIME COMPLETED:
12:29 PM
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On 11/12/20 at 12:00PM, while conducting a tele-visit for pre licensing with applicant, LPA D Panlilio completed a Component III presentation with applicant. The applicant was not physically available to sign this report due to COVID-19 shelter in place order.

As this is a brand new facility, no residents were present during the tele visit. LPA reviewed the Emergency/Disaster plan (LIC 610E), earthquake drill and COVID-19 infection control mitigation and prevention plans with applicant.

LPA reminded applicant of the statute that requires CCL to be notified within 5 business days of admitting their first resident. This notification may be done by phone, mail or fax.

This report was discussed with applicant Comfort Kollie and a copy was provided via email.
SUPERVISOR'S NAME: Rajind BasiTELEPHONE: (510) 286-4201
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2020
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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