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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200664
Report Date: 06/21/2023
Date Signed: 06/21/2023 10:00:59 AM

Document Has Been Signed on 06/21/2023 10:00 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:COLONIAL ACRES RESIDENTIAL CARE HOMEFACILITY NUMBER:
019200664
ADMINISTRATOR:SARAH MAY BALINGITFACILITY TYPE:
740
ADDRESS:18905 STANDISH AVENUETELEPHONE:
(510) 276-0939
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 20CENSUS: 18DATE:
06/21/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Adeliza Magallones, AdministratorTIME COMPLETED:
10:10 AM
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On this day at around 9:15 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct a case management visit to follow up on four residents who needed immediate transfer from Montgomery Springs Manor. LPA met with Administrator Adeliza Magallones and explained the purpose of visit.

During the visit, LPA interviewed 3 out of 4 residents who all state they are doing fine, no issues or concerns. One resident was sleeping. LPA did not observe any immediate health and safety risk.

A copy of this report was provided to Administrator.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2023
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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