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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
079201209
Report Date:
06/05/2023
Date Signed:
06/05/2023 12:13:47 PM
Document Has Been Signed on
06/05/2023 12:13 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:
GRAND OAK MANOR SUITE LLC
FACILITY NUMBER:
079201209
ADMINISTRATOR:
RAMOS, DIGNA
FACILITY TYPE:
740
ADDRESS:
945 FANED WAY
TELEPHONE:
(925) 364-0882
CITY:
CONCORD
STATE:
CA
ZIP CODE:
94518
CAPACITY:
4
CENSUS:
0
DATE:
06/05/2023
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
10:44 AM
MET WITH:
Digna Ramos (applicant-licensee)
TIME COMPLETED:
12:25 PM
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LPA conducted Component III with Licensee/ Administrator. LPA presented Component III Power Point and discussed the regulations embodied in the presentation.
No issues noted during inspection. LPA observed that facility is ready to be licensed. This report will be submitted to the Centralized Application Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required.
Exit interview conducted and a copy of this report will be provided.
SUPERVISOR'S NAME:
Harpreet Humpal
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
Jill Clancy-Czuleger
TELEPHONE:
510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
06/05/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/05/2023
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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