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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201410
Report Date: 10/17/2024
Date Signed: 10/17/2024 12:30:07 PM

Document Has Been Signed on 10/17/2024 12:30 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:HAVEN OF WALNUT CREEK, LLC, THEFACILITY NUMBER:
079201410
ADMINISTRATOR/
DIRECTOR:		GOLUB, JUVYFACILITY TYPE:
735
ADDRESS:560 DOVER DRTELEPHONE:
(925) 954-1865
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY: 6CENSUS: 5DATE:
10/17/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Applicants Howard Golub and Juvy GolubTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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On 10/17/2024 at 10:00 AM, Licensing Program Analysts (LPAs) James Sampair and David Doidge arrived unannounced to conduct a Case Management visit to complete the Prelicensing inspection and the COMP III training. Upon entry into the facility, the LPAs informed the Applicant Juvy Golub of the purpose of the visit.

The facility passed pre-licensing inspection and completed the Component III training.

The license will be issued after Central Applications Bureau analyst completes the final review of the application.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2024
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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