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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201272
Report Date: 09/21/2023
Date Signed: 09/21/2023 12:10:30 PM

Document Has Been Signed on 09/21/2023 12:10 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:PERRY'S PLACE- EL MONTEFACILITY NUMBER:
079201272
ADMINISTRATOR:PERRY, LATISHAFACILITY TYPE:
735
ADDRESS:3962 EL MONTE RDTELEPHONE:
(415) 535-1472
CITY:EL SOBRANTESTATE: CAZIP CODE:
94803
CAPACITY: 4CENSUS: 0DATE:
09/21/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Latisha Perry, ApplicantTIME COMPLETED:
02:00 PM
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On 09/21/23 while at the facility for another reason, Licensing Program Analyst (LPA) D Panlilio conducted a component III presentation with administrator (ADM)/ applicant.

LPA discussed the common deficiencies that adult residential facilities are cited on, Title 22 regulations on infection control, physical plant, personnel requirements on clearances and associations, training, emergency/disaster/food requirements, etc. ADM agrees to comply with Title 22 regulations.

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

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2023
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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