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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015700162
Report Date: 09/19/2023
Date Signed: 09/19/2023 12:43:50 PM

Document Has Been Signed on 09/19/2023 12:43 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:CHANG, ANNYFACILITY NUMBER:
015700162
ADMINISTRATOR:CHANG, ANNYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 579-2118
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
09/19/2023
TYPE OF VISIT:Case Management - Licensee InitiatedANNOUNCEDTIME BEGAN:
12:34 PM
MET WITH:Anny ChangTIME COMPLETED:
01:35 PM
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Licensing Program Analyst Sidney Cortez met with Licensee Anny Chang. There are no children in care. Licensee stated that she does not have any children in her roster for the last 5 months due to family matters.

She had decided to go inactive status and filled up the LIC 9211. LPA Cortez filed the form.
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Sidney Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2023
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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