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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200540
Report Date: 11/17/2023
Date Signed: 11/17/2023 01:35:51 PM


Document Has Been Signed on 11/17/2023 01:35 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:JUDSONVILLE HEIGHTSFACILITY NUMBER:
079200540
ADMINISTRATOR:GONZALEZ, EMERITO RAMONFACILITY TYPE:
740
ADDRESS:5228 JUDSONVILLE DRTELEPHONE:
(925) 757-3620
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY:6CENSUS: 0DATE:
11/17/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Minerva Gonzalez, Administrator/LicenseeTIME COMPLETED:
03:30 PM
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On 11/17/23 at 1:30PM, Licensing Program Analyst (LPA) D Panlilio conducted an announced case management visit for facility closure with administrator/licensee. LPA explained the purpose of the visit with licensee who stated that she is closing the facility because she is retiring.

LPA toured the facility with licensee. LPA observed no residents living at the facility.
LPA observed all facility signages (COVID-19 posters, Complaint posters, Personal Rights, Emergency/Disaster & infection control plans, contact information) have been removed. Administrator/Licensee stated they worked with Regional Center of the East Bay (RCEB) in safely relocating all residents to other facilities on 11/08/23. Administrator/Licensee surrendered the facility license to LPA during visit.

LPA advised forfeiture letter will be mailed to Administrator/Licensee once complete.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2023
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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