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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201188
Report Date: 10/27/2022
Date Signed: 10/27/2022 12:37:49 PM

Document Has Been Signed on 10/27/2022 12:37 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:EL REY HOME, THEFACILITY NUMBER:
079201188
ADMINISTRATOR:HAMILTON, LORELLFACILITY TYPE:
740
ADDRESS:2717 EL REY STREETTELEPHONE:
(415) 601-0243
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 3CENSUS: 0DATE:
10/27/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Lorell Hamilton, ApplicantTIME COMPLETED:
02:23 PM
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On 10/27/22 at 1PM, a Component III presentation was also completed during the Pre-licensing inspection with the applicant. Common deficiencies and regulations were discussed with the applicant who understood and agreed to comply with Title 22 regulations in the operation of the residential care facility.

The applicant was reminded of the statute that requires CCL to be notified within 5 business days of admitting their first resident. This notification may be done by phone, by mail, or by fax.

This report was discussed with the applicant and a copy was provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2022
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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