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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201128
Report Date: 09/15/2022
Date Signed: 09/15/2022 03:04:52 PM

Document Has Been Signed on 09/15/2022 03:04 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:NICOLE HOMEFACILITY NUMBER:
079201128
ADMINISTRATOR:FERNANDEZ, FERNANDO C.FACILITY TYPE:
735
ADDRESS:613 MARATHON DRIVETELEPHONE:
(510) 861-5810
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 6CENSUS: DATE:
09/15/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:31 PM
MET WITH:Fernando Fernandez, ApplicantTIME COMPLETED:
03:35 PM
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Licensing Program Analyst (LPA) L. Ibo conducted an announced Component III Training. Component III was attended by Fernando Fernandez, applicant/administrator and Angelina Erasquin, applicant

LPA presented Component III power point and discussed the regulations embodied in the power point. LPA observed Licensee/Administrator gained knowledge about running and maintaining the facility in accordance with regulations.

LPA discussed with applicant regarding covid19 infection control.

Exit interview conducted and a copy of report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2022
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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