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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
079201110
Report Date:
01/03/2022
Date Signed:
01/03/2022 02:32:03 PM
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:
CATERED CARE
FACILITY NUMBER:
079201110
ADMINISTRATOR:
GUTIERREZ, JONATHAN
FACILITY TYPE:
740
ADDRESS:
1312 5TH AVE
TELEPHONE:
(925) 286-2221
CITY:
CONCORD
STATE:
CA
ZIP CODE:
94518
CAPACITY:
4
CENSUS:
DATE:
01/03/2022
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
12:50 PM
MET WITH:
Jonathan Gutierrez (applicant-administrator)
TIME COMPLETED:
02:40 PM
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Licensing Program Analysts (LPA) Jill Clancy-Czuleger conducted an announced Component III Training. Component III was attended by Jonathan Gutierrez (applicant-administrator)
LPA J. Clancy-Czuleger 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
SUPERVISOR'S NAME:
Harpreet Humpal
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
Jill Clancy-Czuleger
TELEPHONE:
510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
01/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/03/2022
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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