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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201289
Report Date: 08/28/2023
Date Signed: 08/28/2023 11:32:18 AM


Document Has Been Signed on 08/28/2023 11:32 AM - 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:SUPRA HOMESFACILITY NUMBER:
079201289
ADMINISTRATOR:GAUTAM, SUJANFACILITY TYPE:
740
ADDRESS:6224 N ARLINGTON BLVDTELEPHONE:
(318) 243-5254
CITY:SAN PABLOSTATE: CAZIP CODE:
94806
CAPACITY:6CENSUS: 0DATE:
08/28/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Sujan Gautam, AdministratorTIME COMPLETED:
11:35 AM
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On 08/28/2023 at 11:00 AM, Licensing Program Analyst (LPA) P. Watson conducted a face to face Component III presentation with Administrator, Sujan Gautam.


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.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris WatsonTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2023
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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