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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
079201104
Report Date:
11/30/2021
Date Signed:
11/30/2021 03:02:45 PM
Document Has Been Signed on
11/30/2021 03:02 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:
GOMES HOME ADULT RESIDENTIAL FACILITY
FACILITY NUMBER:
079201104
ADMINISTRATOR:
GOOLSBY, DEON
FACILITY TYPE:
735
ADDRESS:
2717 GARVIN AVENUE
TELEPHONE:
(510) 259-8337
CITY:
RICHMOND
STATE:
CA
ZIP CODE:
94804
CAPACITY:
4
CENSUS:
3
DATE:
11/30/2021
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
01:30 PM
MET WITH:
Dejon Gomes/Applicant and
Deon Goolsby/Administrator
TIME COMPLETED:
03:05 PM
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Licensing Program Analysts (LPAs) Alicia Delmundo and Lisha Holmes conducted Component III Training via Teams Meeting. Component III was attended by Dejon Gomes (applicant) and Deon Goolsby (administrator).
LPA Delmundo presented the training via Power Point presentation.
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:
11/30/2021
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/30/2021
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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