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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
486801728
Report Date:
10/24/2023
Date Signed:
10/24/2023 09:53:23 AM
Document Has Been Signed on
10/24/2023 09:53 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
CCLD Regional Office
,
1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA
,
CA
95405
FACILITY NAME:
GLAJAN CARE, INC.
FACILITY NUMBER:
486801728
ADMINISTRATOR:
MILES, GLADYS
FACILITY TYPE:
735
ADDRESS:
163 DEVONSHIRE ST.
TELEPHONE:
(707) 656-6012
CITY:
VALLEJO
STATE:
CA
ZIP CODE:
94591
CAPACITY:
6
CENSUS:
4
DATE:
10/24/2023
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
09:30 AM
MET WITH:
Dinette Thompson
TIME COMPLETED:
10:00 AM
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Licensing Program Analyst Leibert arrives unannounced for the purpose of amending the complaint document originally created on 10/09/2023. The document was amended to delete a pronoun in order to maintain confidentiality of the referenced party.
Report left.
No citations issued today.
SUPERVISORS NAME
:
Carla Martinez
LICENSING EVALUATOR NAME
:
David Leibert
LICENSING EVALUATOR SIGNATURE
:
DATE:
10/24/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/24/2023
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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