<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201123
Report Date: 04/06/2022
Date Signed: 04/06/2022 11:49:28 AM

Document Has Been Signed on 04/06/2022 11:49 AM - 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:LEE FAMILY CARE HOME #4FACILITY NUMBER:
079201123
ADMINISTRATOR:TUCKER, WILLIAMFACILITY TYPE:
735
ADDRESS:18 BROOKS CTTELEPHONE:
(925) 354-2254
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 6CENSUS: 5DATE:
04/06/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:William Tucker, Administrator & Maureen Lee, LicenseeTIME COMPLETED:
10:30 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 4/6/2022 starting at 9:45AM Licensing Program Analyst (LPA) L. Ibo conducted a health and safety check as a result of department receiving a priority 1 complaint. LPA met with William Tucker, Administrator and Maureen Lee, Licensee. No clients observe during the visit, 3 clients are at the day program and 2 clients are working during the day.

During the health and safety check, LPA toured the building with Maureen Lee including but not limited to common areas, bathrooms, bedrooms and outdoor area. LPA observed smoke detectors and carbon monoxide detector throughout facility.

Facility appear to be safe and there are no imminent health/safety concerns on today's date. Facility is maintained at a comfortable temperature for the clients in care.

No deficiencies were cited today.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/06/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1