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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201090
Report Date: 09/13/2021
Date Signed: 09/13/2021 11:43:55 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 SPRINGTIME RESIDENCEFACILITY NUMBER:
079201090
ADMINISTRATOR:TRUCKS, CHRISTINAFACILITY TYPE:
740
ADDRESS:2752 MOHAWK CR.TELEPHONE:
(415) 290-7611
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY:6CENSUS: 6DATE:
09/13/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Christina Trucks, Licensee/AdministratorTIME COMPLETED:
11:55 AM
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On 9/13/2021 at 11:10am, Licensing Program Analyst (LPA) L. Francisco conducted a Component III presentation with Licensee/Administrator, Christina Trucks.

LPA presented Component III power point and discussed the regulations embodied in the power point. LPA observed Licensee/Administrator gained knowledge about running and maintaining the facility in accordance with regulations.

Exit interview conducted and a copy of report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2021
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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