<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201246
Report Date: 07/07/2023
Date Signed: 07/07/2023 12:28:59 PM

Document Has Been Signed on 07/07/2023 12:28 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:CONTRA LOMA HOME LLCFACILITY NUMBER:
079201246
ADMINISTRATOR:LI, LUFACILITY TYPE:
735
ADDRESS:4131 SHELTER COVE COURTTELEPHONE:
(925) 826-6557
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY: 6CENSUS: 0DATE:
07/07/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:18 PM
MET WITH:Lu Li, ApplicantTIME COMPLETED:
12:40 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 07/07/23 at 12:18 PM, LPA D Panlilio conducted a component III presentation with applicant.

During the Component lll presentation, LPA provided applicant information on how to operate the facility within Title 22 regulatory compliance as well as how to avoid common problem areas. Applicant confirmed understanding of regulations discussed and agreed to comply with Title 22 regulations.

Exit interview conducted and a copy of this report provided
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1