Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 070209920
Report Date: 04/21/2015 12:00:00 AM
Date Signed 04/21/2015 08:58:22 AM

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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:SRVSACCA - KIDS COUNTRY-BOLLINGER CANYONFACILITY NUMBER:
070209920
ADMINISTRATOR:NG, CELINAFACILITY TYPE:
840
ADDRESS:2300 TALAVERA DRIVETELEPHONE:
(925) 275-0574
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY:126CENSUS: 14DATE:
04/21/2015
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Kiki AlexiouTIME COMPLETED:
09:00 AM
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LPA Dayna Collier met with Assistant Director Kiki Alexiou for a case management visit as a result of receiving an unusual incident report.

As a result of this visit, there were no deficiencies cited.
SUPERVISOR'S NAME: Zakiya AliTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Dayna CollierTELEPHONE: 510-725-7010
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2015
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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