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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200565
Report Date: 12/11/2024
Date Signed: 12/11/2024 11:49:17 AM

Document Has Been Signed on 12/11/2024 11:49 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:COZY FAMILY CAREFACILITY NUMBER:
079200565
ADMINISTRATOR/
DIRECTOR:		JI, RUIFACILITY TYPE:
740
ADDRESS:2135 LUPINE ROADTELEPHONE:
(510) 327-4408
CITY:HERCULESSTATE: CAZIP CODE:
94547
CAPACITY: 6CENSUS: 4DATE:
12/11/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Marilyn Pantonial, New Ownership/ Adminstrator TIME VISIT/
INSPECTION COMPLETED:
10:30 AM
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On 12/11/24 at 9:40AM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct a POC visit for a previous Pre-Licensing visit due to change of ownership. LPA greeted by care staff Celia Garcia and Administrator, Marilyn Pantonial (ADM of new Change of Ownership) was informed via phone and explained the purpose of the visit. Marilyn arrived at a later time.

LPA toured the facility and observed knifes are locked in the kitchen cabinet. Medication is locked in medication cabinet. There are new a screen on the kitchen window. The facility has a minimum of 7-days of non-perishables and 2-days of perishables foods. The garage storage is cleared. Backyard is cleared without any garden equipment. LPA will cleared all deficiencies.




Exit interview is conducted an a copy of this report is provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2024
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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