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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
079201088
Report Date:
12/16/2021
Date Signed:
12/16/2021 02:52:45 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:
LAFAYETTE RESIDENTIAL CARE
FACILITY NUMBER:
079201088
ADMINISTRATOR:
MCGILL, TAMRA
FACILITY TYPE:
740
ADDRESS:
1300 JUANITA DRIVE
TELEPHONE:
(925) 945-6833
CITY:
WALNUT CREEK
STATE:
CA
ZIP CODE:
94595
CAPACITY:
6
CENSUS:
3
DATE:
12/16/2021
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
01:30 PM
MET WITH:
Tamra McGill, Applicant
TIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) C. Lin and L. Hall conducted a face to face Component III presentation on 12/16/2021 starting at 1:30 pm. LPAs met with applicant Tamra McGill respectively.
LPAs presented Component III power point and discussed the regulations embodied in the power point. LPAs observed the participant gained knowledge about running and maintaining the facility in accordance with regulations.
Exit interview conducted with Tamra McGill and a copy provided.
SUPERVISOR'S NAME:
Bennett Fong
TELEPHONE:
(510) -62-2621
LICENSING EVALUATOR NAME:
Catherine Lin
TELEPHONE:
510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE:
12/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/16/2021
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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