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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201128
Report Date: 09/29/2023
Date Signed: 09/29/2023 10:30:25 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/29/2023 10:30 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: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: 0DATE:
09/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Fernando Fernandez, Licensee TIME COMPLETED:
10:45 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 09/29/2022 at 9:30 am Licensing Program Analyst (LPAs) J. Clancy-Czuleger arrived unannounced for a Health and Safety Check. LPA met with Licensee Fernando Fernandez.

During the visit LPA observed that there are currently no resident residing at the facility. Licensee stated that they are still in the process of being vendorized and will be looking for residents as soon as that is completed. LPA checked Carbon Monoxide detector, Smoke Detector, Fire Extinguisher and Emergency Exits. The fire extinguishers were serviced by the fire marshal on August 29, 2023.

LPA reminded the Licensee to contact the department once they get residents so a post licensing inspection can occur.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2023
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