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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201135
Report Date: 05/02/2022
Date Signed: 05/02/2022 02:55:37 PM

Document Has Been Signed on 05/02/2022 02:55 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:UPPER ROOM OF SAN RAMON LLCFACILITY NUMBER:
079201135
ADMINISTRATOR:CASIPIT, ANGELITAFACILITY TYPE:
735
ADDRESS:3295 ENSENADA DR.TELEPHONE:
(925) 216-5271
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY: 6CENSUS: 4DATE:
05/02/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Angelita Casipit, Licensee/AdministratorTIME COMPLETED:
03:05 PM
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On 5/2/2022 at 2:00 PM, Licensing Program Analysts (LPAs) L. Francisco and L. Fici arrived unannounced to conduct Component III Presentation. Upon arrival, LPAs were greeted by Lead Staff, Ronald Corum. Administrator, Angelita Casipit later arrived at 2:30 PM.

During the visit, LPAs conducted a face to face Component III presentation starting at 2:35 PM with Administrator.

LPAs presented Component III power point and discussed the regulations embodied in the power point. LPAs observed participants gained knowledge about running and maintaining the facility in accordance with regulations.

LPAs observed that facility is ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed, and is subject to final approval by CAU. Additional requirements may still be required.

Exit interview conducted and a copy of report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Lizette Francisco
LICENSING EVALUATOR SIGNATURE: DATE: 05/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2022
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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