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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201040
Report Date: 05/27/2021
Date Signed: 05/27/2021 02:09:34 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:CATHEDRAL CARE HOMEFACILITY NUMBER:
079201040
ADMINISTRATOR:DATUIN, MARIVICFACILITY TYPE:
740
ADDRESS:2707 CATHEDRAL CIRCLETELEPHONE:
(925) 222-8492
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:6CENSUS: 0DATE:
05/27/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Marivic DatuinTIME COMPLETED:
02:15 PM
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On 5/27/2021 Continuation of pre-licensing was conducted… LPA (Licensing Program Analyst) Leslie Ibo met with applicant Marivic Datuin, facility was toured. LPA verified that A1 is no longer living at the facility. Applicant Marivic Datuin sent statement letter verifying A1 will not be at the facility until fingerprint clearance is receive.

This report will be submitted to the Centralized Application Bureau (CAB) and a final review of the
application will be conducted. This facility is not yet licensed and is subject to final approval by CAB.
Additional requirements may still be required.

Exit interview conducted with Applicant and a copy of report will be emailed.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2021
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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