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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601315
Report Date: 08/19/2024
Date Signed: 08/19/2024 02:20:06 PM


Document Has Been Signed on 08/19/2024 02:20 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:ISHERWOOD CARE IIIFACILITY NUMBER:
015601315
ADMINISTRATOR:CAYABYAB, LAURO & ZORAIDAFACILITY TYPE:
740
ADDRESS:1445 SKELTON AVENUETELEPHONE:
(510) 894-4571
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY:6CENSUS: 5DATE:
08/19/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Larry Cayabyab, AdministratorTIME COMPLETED:
02:30 PM
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While at the facility for the annual inspection on 08/19/2024, Licensing Program Analysts (LPAs) P. Manalo and J. Clancy-Czuleger requested updated copies of the following documents:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
Current Administrator’s Certificate


Administrator Larry Cayabyab agrees to submit the documents to CCLD by //

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-4201
LICENSING EVALUATOR NAME: Patricia ManaloTELEPHONE: (916) 432-7785
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2024
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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