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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201090
Report Date: 04/07/2023
Date Signed: 04/07/2023 03:58:06 PM


Document Has Been Signed on 04/07/2023 03:58 PM - It Cannot Be Edited

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:
04/07/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Isagani Silvesetre, AdministratorTIME COMPLETED:
04:05 PM
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On 4/7/2023 starting at 2:55 PM, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to conduct a POC (proof of correction) inspection. LPA met with Administrator, Isagani Silvestre and explained the purpose of the visit. LPA spoke to Licensee over the phone.

Facility has the following deficiency that was not cleared:
HSC 1569.652(c); LPA.L. Francisco did not receive POC due on 3/24/23 and licensee have not provided the documents.

Civil Penalties in the amount of $1,400 is assess today for the period of 3/25/23 to 4/7/23 for failure to meet POC date for deficiency HSC 1569.652(c). Facility is subject to ongoing civil penalties until deficiency is corrected.

Licensee authorized Administrator, Isagani Silvestre to sign.


Exit interview conducted. A copy of this report, civil penalty, and appeal rights provided via email to Licensee.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2023
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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