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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201192
Report Date: 10/05/2023
Date Signed: 10/05/2023 10:58:18 AM

Document Has Been Signed on 10/05/2023 10:58 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:MOM BOARD AND CARE SERVICES, INC.FACILITY NUMBER:
019201192
ADMINISTRATOR:PAONGO, FALEMEI MAHEFACILITY TYPE:
740
ADDRESS:2301 90TH AVETELEPHONE:
(510) 866-6660
CITY:OAKLANDSTATE: CAZIP CODE:
94603
CAPACITY: 6CENSUS: DATE:
10/05/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:04 AM
MET WITH:Falemei Mahe Paongo, CEO/AdministratorTIME COMPLETED:
10:41 AM
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Facility Type: RCFE
Application Type: Initial
Capacity: 6
Census: 2
COMP II Participant: Falemei Mahe Paongo, CEO/Administrator
Interview Method: Telephone interview

On 10/5/23, applicant/administrator participated in COMP II. Identification of the applicant/administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant/administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISORS NAME: Mirella Quaranta
LICENSING EVALUATOR NAME: Anna Barrios
LICENSING EVALUATOR SIGNATURE: DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/05/2023
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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