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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201215
Report Date: 02/01/2023
Date Signed: 02/01/2023 04:10:30 PM

Document Has Been Signed on 02/01/2023 04:10 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:PATO LANE HOMEFACILITY NUMBER:
079201215
ADMINISTRATOR:BENITEZ, KEITH PAUL AFACILITY TYPE:
735
ADDRESS:3847 PATO LANETELEPHONE:
(650) 834-1301
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 6CENSUS: 0DATE:
02/01/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH: KEITH PAUL BENITEZ & REMY BANZUELA, APPLICANT/LICENSEE'STIME COMPLETED:
04:30 PM
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On 02/01/2023 at 1:00PM, Licensing Program Analyst (LPA) L. Ibo conducted a Component III Review, for the Pre-licensing Inspection which was conducted on this day. Component III was discussed with KEITH PAUL BENITEZ & REMY BANZUELA, APPLICANT/LICENSEE'S.

LPA presented Component III power point during visit and discussed the regulations embodied in the power point. LPA discussed covid19 protocols with applicants.

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: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 02/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/01/2023
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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