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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015700168
Report Date: 10/17/2023
Date Signed: 10/17/2023 02:16:50 PM

Document Has Been Signed on 10/17/2023 02:16 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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:RAJ, BETSYFACILITY NUMBER:
015700168
ADMINISTRATOR:RAJ, BETSYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 396-8988
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
10/17/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:37 PM
MET WITH:Betsy RajTIME COMPLETED:
03:46 PM
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On Oct 17 2023 Betsy Raj requested for LOA Cortez to check if the 2 other rooms are are within health and safety standards for she plans to place them on limits.

LPA Cortez provided technical advice and gave consultation to the physical plants modifications needed

Licensee will create modifications and will notify LPA Cortez when done modifying.
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Sidney Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2023
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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