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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201061
Report Date: 05/14/2021
Date Signed: 05/14/2021 01:48:17 PM

Document Has Been Signed on 05/14/2021 01:48 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:CROW CANYON RESIDENTIAL CARE IIIFACILITY NUMBER:
079201061
ADMINISTRATOR:YU, RUFFYFACILITY TYPE:
740
ADDRESS:2254 DOVER WAYTELEPHONE:
(925) 732-2691
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY: 6CENSUS: 0DATE:
05/14/2021
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Ruffy Yu, LicenseeTIME COMPLETED:
01:50 PM
NARRATIVE
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On 05/14/2021, at 1:20pm, Licensing Program Analyst (LPA), L. Hall conducted a face to face Component III presentation.. LPA met with Licensee, Ruffy Yu.

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 with Licensee and a copy of this report provided,
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 05/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/14/2021
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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