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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 071440577
Report Date: 02/07/2024
Date Signed: 02/13/2024 10:10:51 AM


Document Has Been Signed on 02/13/2024 10:10 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 02/13/2024 09:58 AM

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

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On 02/07/2024 at 2:40 PM, Licensing Program Analyst (LPA) James Sampair arrived unannounced to conduct a required annual inspection. LPA explained the purpose of the visit to Licensee / Administrator Florentino "Tina" Budomo.

The LPA inspected facility inside and out. LPA reviewed files of 4 residents and 5 staff members. There were at least 7 days of nonperishable and 2 days of perishable foods. Temperature in the facility at 3:36 PM was measured at 71.2 degrees in the living room. Fire extinguisher was fully charged and serviced on 3/27/2023. Carbon monoxide and smoke detectors operational. Administrator is on site a minimum of 20 hours a week to oversee proper business operation.

No citations issued during inspection.

Exit interview conducted with Licensee for whom a copy of this report was provided via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2024
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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