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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201067
Report Date: 05/05/2021
Date Signed: 05/05/2021 09:03:57 AM

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 FAMILY OF CARE NO. 2FACILITY NUMBER:
079201067
ADMINISTRATOR:WILLIAMS, BRENDAFACILITY TYPE:
740
ADDRESS:2410 SMITH RDTELEPHONE:
(925) 876-6746
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:6CENSUS: 0DATE:
05/05/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Brian FriedelTIME COMPLETED:
09:00 AM
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This is continuation of pre-licensing requirement. LPA (Licensing Program Analyst) L.Ibo conducted pre-licensing on 04/30/2021, there was additional requirement that wasn't completed during the pre-licensing inspection, which was an operating telephone available to residents.

Today, 05/05/2021 LPA verified that the facility has an operating telephone available to future residents , therefore LPA recommends the facility for license.

LPA also updated facility profile under licensing information system (LIS) , mobile number and telephone number was updated.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

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

DATE: 05/05/2021
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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