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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201033
Report Date: 12/28/2023
Date Signed: 12/28/2023 08:19:31 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 12/28/2023 08:19 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:RELEVE HOMECAREFACILITY NUMBER:
019201033
ADMINISTRATOR:VALES, RECYFACILITY TYPE:
740
ADDRESS:33012 CORNING CTTELEPHONE:
(714) 469-4413
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:4CENSUS: 0DATE:
12/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
07:00 AM
MET WITH:Administrator, Recy ValesTIME COMPLETED:
08:27 AM
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Licensing program analyst (LPA) A. Gomez attempted a required 1 year inspection on 12/21/2023 at 8:00AM.

On todays date at 7:00AM LPA arrived unannounced to conduct the required 1 year inspection. LPA met with Administrator, Recy Vales and explained the purpose of the visit.

Upon arrival administrator explained that there are no residents and facility has never been operated or maintained any residents. The facility is licensed for four (4) ambulatory.

On todays date administrator forfeited her licence and requested that facility be closed. LPA toured facility and observed that there are no residents or resident belongings. LPA obtained an official letter requesting that facility be closed and licence be voided during visit. Administrator will send in the hard copy of Licence to CCLD at a later date.

LPA informed administrator that there is a balance due of $742 for annual fees.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2023
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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