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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201352
Report Date: 12/11/2024
Date Signed: 12/11/2024 11:57:47 AM

Document Has Been Signed on 12/11/2024 11:57 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:COZY FAMILY CAREFACILITY NUMBER:
079201352
ADMINISTRATOR/
DIRECTOR:		PANTONIAL, MARILYNFACILITY TYPE:
740
ADDRESS:2135 LUPINE ROADTELEPHONE:
(650) 201-1634
CITY:HERCULESSTATE: CAZIP CODE:
94547
CAPACITY: 6CENSUS: 4DATE:
12/11/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Marilyn Pantonial, New OwnershipTIME VISIT/
INSPECTION COMPLETED:
12:25 PM
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On 12/11/24 at 10:30 a.m., Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct a POC visit for a previous Pre-Licensing visit due to change of ownership. LPA met with Administrator, Marilyn Pantonial (ADM of new Change of Ownership) and explained the purpose of the visit.

LPA cleared all deficiencies.

No issues noted during inspection. LPA observed that facility is ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. Additional requirements may still be required.



COMP III conduced to new ownership.

Exit interview is conducted an a copy of this report is provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2024
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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