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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201207
Report Date: 12/08/2022
Date Signed: 12/08/2022 06:57:13 PM

Document Has Been Signed on 12/08/2022 06:57 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:PHOENIX RESIDENTIAL HOMEFACILITY NUMBER:
079201207
ADMINISTRATOR:CHAVEZ, CYNTHIAFACILITY TYPE:
735
ADDRESS:2009 RUBYE DRIVETELEPHONE:
(925) 852-8023
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 4CENSUS: 2DATE:
12/08/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
06:50 PM
MET WITH:Cynthia Chavez, Administrator/LicenseeTIME COMPLETED:
07:05 PM
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On 12/08/2022 at 6:50PM, Licensing Program Analyst (LPA) L. Hall conducted a Component III Review, for the Pre-licensing Inspection which was conducted on this date. with Administrator/Licensee, Cynthia Chavez.

LPA presented Component III power point during visit and discussed the regulations embodied in the power point. LPA observed the participant gained knowledge about running and maintaining the facility in accordance with regulations.

A license has not yet been granted to this facility. Licensure is subject to final review and approval by the Centralized Applications Unit. Licensee is not to accept residents until notified by Community Care Licensing that the license has been approved.

Exit interview conduct and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2022
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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