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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201353
Report Date: 06/05/2024
Date Signed: 06/05/2024 01:08:47 PM

Document Has Been Signed on 06/05/2024 01:08 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:YVONNE'S HOME CARE SERVICESFACILITY NUMBER:
079201353
ADMINISTRATOR/
DIRECTOR:		DANIELS, CAROLYNFACILITY TYPE:
740
ADDRESS:2856 SHANE DRIVETELEPHONE:
(510) 964-4600
CITY:RICHMONDSTATE: CAZIP CODE:
94806
CAPACITY: 6CENSUS: 0DATE:
06/05/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:48 AM
MET WITH:Carolyn Daniels, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:10 PM
NARRATIVE
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On 6/05/2024 at 11:48AM, Licensing Program Analyst (LPA), Carol Fowler arrived to conduct an unannounced continuation Pre-Licensing Inspection. LPA met with Administrator, Carolyn Daniels, and explained the purpose of the visit.

LPA reviewed two (2) staff files. All were current.

LPA conducted a Component Review, for the Pre-licensing Inspection which was conducted on 6/05/2024, with Carolyn Daniels, Administrator.

LPA presented Component III power point during visit 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.

Licensure is subject to final review and approval by the Centralized Applications Unit. Licensee is not to accept consumers until notified by Community Care Licensing that the license has been approved.

No deficiencies cited during visit.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 06/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/05/2024
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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