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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600976
Report Date: 04/24/2023
Date Signed: 04/24/2023 09:06:02 AM

Document Has Been Signed on 04/24/2023 09:06 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:QUEENS CARE HOME IIFACILITY NUMBER:
015600976
ADMINISTRATOR:SANTOS, PROTASIO L.FACILITY TYPE:
740
ADDRESS:2724 WILLOWREN WAYTELEPHONE:
(925) 825-7745
CITY:PLEASANTONSTATE: CAZIP CODE:
94566
CAPACITY: 6CENSUS: 0DATE:
04/24/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Jocelyn Santos, Licensee
Protasio Santos, Licensee		TIME COMPLETED:
09:20 AM
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On 4/24/2023 at 8:40AM, Licensing Program Analyst (LPA) G. Luk arrived to conduct a case management inspection regarding facility closure. LPA met with Licensee, Jocelyn Santos and Protasio Santos.

LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, garage, and outdoor areas. LPA observed there was no residents present during inspection. Licensee provided information regarding resident's relocation place. LPA was informed that last resident moved out on 4/15/2023. Licensee provided original license to LPA.

LPA will send forfeiture letter to licensee at a later time.

Exit interview conducted. A copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 04/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/24/2023
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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