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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201192
Report Date: 08/28/2024
Date Signed: 08/28/2024 04:16:51 PM

Document Has Been Signed on 08/28/2024 04:16 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:MOM BOARD AND CARE SERVICES, INC.FACILITY NUMBER:
019201192
ADMINISTRATOR/
DIRECTOR:		PAONGO, FALEMEI MAHEFACILITY TYPE:
740
ADDRESS:2301 90TH AVETELEPHONE:
(510) 866-6660
CITY:OAKLANDSTATE: CAZIP CODE:
94603
CAPACITY: 6CENSUS: 3DATE:
08/28/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Falemei Paongo, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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LPA Greg Clark conducted a face to face Component III presentation on starting at 3:00 pm. LPA met with licensee and administrator, Falemei Paongo.

LPA presented Component III power point and discussed the regulations embodied in the power point. LPA observed the participant gained knowledge about running and maintaining the facility in accordance with regulations.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2024
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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