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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201274
Report Date: 07/14/2023
Date Signed: 07/14/2023 02:24:58 PM

Document Has Been Signed on 07/14/2023 02:24 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:RES SUCCESSFACILITY NUMBER:
079201274
ADMINISTRATOR:BREMNER, IANFACILITY TYPE:
775
ADDRESS:3490 BUSKIRK AVETELEPHONE:
(925) 363-9705
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY: 45CENSUS: 0DATE:
07/14/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:57 PM
MET WITH:Teanna Jerkins, Program ManagerTIME COMPLETED:
02:30 PM
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On 07/14/2023 Licensing Program Analyst (LPA) L. Alexander conducted a face to face Component III presentation with Program Manager, Teanna Jerkins. LPA presented Component III power point and discussed the regulations embodied in the power point. LPA observed participant gained knowledge about running and maintaining the facility in accordance with regulations.

Exit interview conducted and a copy of report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE: DATE: 07/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/14/2023
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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