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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201099
Report Date: 10/10/2022
Date Signed: 10/10/2022 05:49:26 PM

Document Has Been Signed on 10/10/2022 05:49 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:GARCIA'S PLACE, INC.FACILITY NUMBER:
079201099
ADMINISTRATOR:GAVILAN, LOIDAFACILITY TYPE:
735
ADDRESS:1712 SAN JOSE DRIVETELEPHONE:
(925) 565-5731
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 4CENSUS: 3DATE:
10/10/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:50 PM
MET WITH:LOIDA GAVILAN, AdministratorTIME COMPLETED:
06:00 PM
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On 10/10/22 at 3:50PM, Licensing Program Analyst (LPA) C. Lin conducted an unannounced case management visit as a result of receiving 1 self-reported incident and death dated 10/09/22 submitted to CCLD. LPA explained the purpose of the visit with Administrator.

The report indicated that C1 was AWOL. The police department informed licensing and facility Administrator that C1 was shot resulting death outside of facility on 10/08/2022.

During visit, LPA reviewed and obtained relevant documentation. The case was referred to CCLD Investigation Bureau for needs further.

Exit interview conducted with Administrator and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2022
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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