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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201151
Report Date: 04/18/2022
Date Signed: 04/18/2022 03:59:20 PM

Document Has Been Signed on 04/18/2022 03:59 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:HERITAGE HOME ARFFACILITY NUMBER:
079201151
ADMINISTRATOR:BONIFACIO, ALFREDO JRFACILITY TYPE:
735
ADDRESS:14 RED BARN CT.TELEPHONE:
(925) 679-0845
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 6CENSUS: 5DATE:
04/18/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Alfredo Bonifacio, applicantTIME COMPLETED:
04:15 PM
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On 4/18/2022 Licensing Program Analyst (LPA) L. Ibo unannounced conducted pre-licensing inspection. LPA met with Applicant Alfredo Bonifacio Jr. Facility has census of 5. LPA observed 4 clients were present during today’s visit with 1 client out and at a day program.

Component III completed.

No issues noted during inspection. LPA 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 with Applicant Alfredo Bonifacio Jr. and a copy of report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2022
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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