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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440810
Report Date: 02/01/2024
Date Signed: 02/01/2024 03:39:50 PM


Document Has Been Signed on 02/01/2024 03:39 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:MAG'S REST HOMEFACILITY NUMBER:
011440810
ADMINISTRATOR:SANTILLAN, LORNA & DANILOFACILITY TYPE:
740
ADDRESS:6002 BELLHAVEN AVENUETELEPHONE:
(510) 795-0775
CITY:NEWARKSTATE: CAZIP CODE:
94560
CAPACITY:8CENSUS: 0DATE:
02/01/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Lorna SantillanTIME COMPLETED:
04:00 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 this day at around 3pm, Licensing Program Analyst (LPA) Luisa Fontanilla arrived announced to conduct case management closure visit and met with Administrator Lorna Santillan.

During the visit, LPA inspected the facility inside and out including but not limited to bedrooms, bathrooms, kitchen, dining and backyard. LPA did not observe any resident at the facility during the visit. The Administrator states that a family member will be living in the home. The Administrator surrendered the original facility license during the visit.

A copy of this report was provided to the Administrator.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2024
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