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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 11:44:05 AM
Document Has Been Signed on
11/18/2024 11:44 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 LLC
FACILITY NUMBER:
019201376
ADMINISTRATOR/
DIRECTOR:
CHAN, COELESTIS P.
FACILITY TYPE:
740
ADDRESS:
674 GLENEAGLE AVENUE
TELEPHONE:
(650) 580-5285
CITY:
HAYWARD
STATE:
CA
ZIP CODE:
94544
CAPACITY:
6
CENSUS:
4
DATE:
11/18/2024
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:
Coelestis Chan, Applicant Administrator
TIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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An Comp III associated with Pre-Licensing Inspection done on 11/18/2024 at 10:30 AM was conducted by Licensing Program Analyst (LPA) K. Nguyen. Comp III was attended by Coelestis Chan Applicant.
LPA concluded Comp III.
No citation made during this visit. Exit interview conducted 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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