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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200505
Report Date: 06/20/2023
Date Signed: 06/20/2023 01:41:03 PM


Document Has Been Signed on 06/20/2023 01:41 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:BELOVED HOME RETREATFACILITY NUMBER:
019200505
ADMINISTRATOR:BYRON TRIPPFACILITY TYPE:
740
ADDRESS:41223 CHILTERN DRIVETELEPHONE:
(510) 656-9654
CITY:FREMONTSTATE: CAZIP CODE:
94539
CAPACITY:6CENSUS: 5DATE:
06/20/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Ramon Barrera, Jr.TIME COMPLETED:
02:00 PM
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On this day at around 1:10 pm, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct case management visit to follow up on one resident that needed immediate placement from Montgomery Springs Manor. LPA spoke with Administrator Mirriam Paras and she authorized staff Ramon Barrera to sign the report.

During the visit, LPA interviewed Resident 1 (R1) who states that everything is fine at the facility.

There are no immediate health and safety concerns observed during the visit.

A copy of this report was provided to Barrera.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023
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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