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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
079201357
Report Date:
06/18/2024
Date Signed:
06/18/2024 02:56:11 PM
Document Has Been Signed on
06/18/2024 02:56 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:
CANADA HILLS MANOR
FACILITY NUMBER:
079201357
ADMINISTRATOR/
DIRECTOR:
LIPARDO, MELISSA
FACILITY TYPE:
740
ADDRESS:
5116 CANADA HILLS DR.
TELEPHONE:
(727) 656-9980
CITY:
ANTIOCH
STATE:
CA
ZIP CODE:
94531
CAPACITY:
4
CENSUS:
0
DATE:
06/18/2024
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:
Melissa Lipardo, Administrator
TIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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LPA Greg Clark conducted a face to face Component III presentation on 6/18/24. LPA met with Administrator Melissa Lipardo.
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 and a copy of this report provided.
SUPERVISORS NAME
:
Yvonne Flores-Larios
LICENSING EVALUATOR NAME
:
Gregory Clark
LICENSING EVALUATOR SIGNATURE
:
DATE:
06/18/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/18/2024
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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