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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
079201156
Report Date:
05/23/2022
Date Signed:
05/23/2022 12:43:28 PM
Document Has Been Signed on
05/23/2022 12:43 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:
SAFE SPACE RESIDENTIAL CARE HOME
FACILITY NUMBER:
079201156
ADMINISTRATOR:
EDWARDS, JAMES
FACILITY TYPE:
735
ADDRESS:
650 8TH STREET
TELEPHONE:
(510) 776-3217
CITY:
RICHMOND
STATE:
CA
ZIP CODE:
94801
CAPACITY:
3
CENSUS:
0
DATE:
05/23/2022
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
12:00 PM
MET WITH:
James Edwards, Administrator
TIME COMPLETED:
01:00 PM
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LPA Carol Fowler and Laura Hall conducted a face to face Component III presentation on 05/23/2022 starting at 12:00 pm. LPAs met with administrator James Edwards.
LPAs presented Component III power point and discussed the regulations embodied in the power point. LPAs observed the participant gained knowledge about running and maintaining the facility in accordance with regulations.
Exit interview conducted with a copy provided.
SUPERVISORS NAME
:
Bennett Fong
LICENSING EVALUATOR NAME
:
Carol Fowler
LICENSING EVALUATOR SIGNATURE
:
DATE:
05/23/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/23/2022
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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