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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
079201100
Report Date:
10/27/2021
Date Signed:
10/27/2021 04:07:56 PM
Document Has Been Signed on
10/27/2021 04:07 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:
LIFESPRING HOME
FACILITY NUMBER:
079201100
ADMINISTRATOR:
OGLOBOSELE, ANNE
FACILITY TYPE:
735
ADDRESS:
3711 LINDERO DRIVE
TELEPHONE:
(510) 451-0785
CITY:
CONCORD
STATE:
CA
ZIP CODE:
94519
CAPACITY:
4
CENSUS:
0
DATE:
10/27/2021
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
01:15 PM
MET WITH:
Anne Oglobosele/Applicant-Administrator and
Clifford Oglobosele/Applicant-License.
TIME COMPLETED:
04:10 PM
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Licensing Program Analysts (LPAs) Alicia Delmundo and Jill Clancy-Czuleger conducted an announced Component III Training via Teams Meeting. Component III was attended by Anne Oglobosele (applicant-administrator) and Clifford Oglobosele (applicant-licensee).
LPA Delmundo presented the training via Power Point presentation and had a discussion with applicants.
Exit interview conducted and copy of this report provided at the conclusion of the training
SUPERVISORS NAME
:
Bennett Fong
LICENSING EVALUATOR NAME
:
Alicia Delmundo
LICENSING EVALUATOR SIGNATURE
:
DATE:
10/27/2021
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/27/2021
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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