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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201376
Report Date: 11/18/2024
Date Signed: 11/18/2024 11:43:05 AM

Document Has Been Signed on 11/18/2024 11:43 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:BLOOMSTONE FAMILY HOME LLCFACILITY NUMBER:
019201376
ADMINISTRATOR/
DIRECTOR:		CHAN, COELESTIS P.FACILITY TYPE:
740
ADDRESS:674 GLENEAGLE AVENUETELEPHONE:
(650) 580-5285
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY: 6CENSUS: 4DATE:
11/18/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Coelestis Chan, Applicant AdministratorTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
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On 11/18/2024 at 9:30am, Licensing Program Analyst (LPA) K. Nguyen conducted a second unannounced pre-licensing visit. LPA met with Coelestis Chan, Applicant Administrator, and explained the purpose of the visit. Administrator application is for 6 (six) total capacity, 6 non-ambulatory (all).

LPA inspected the issues that were noted during the second pre-licensing visit. All issues are corrected and observed.

COMP III will be conducted


No issues were noted during inspection. LPA observed that facility is ready to be licensed. This report will be submitted to the Central Applications Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required.

Exit interview conducted with Licensee and a copy of this report provided.


SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2024
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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