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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
010213589
Report Date:
04/13/2017
Date Signed:
03/17/2022 01:44:07 PM
Document Has Been Signed on
03/17/2022 01:44 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, SUITE 1102
OAKLAND
,
CA
94612
FACILITY NAME:
LOPEZ, BERNARDITA & DOMINGO
FACILITY NUMBER:
010213589
ADMINISTRATOR:
LOPEZ, BERNARDITA
FACILITY TYPE:
810
ADDRESS:
TELEPHONE:
(510) 888-9853
CITY:
HAYWARD
STATE:
CA
ZIP CODE:
94544
CAPACITY:
12
TOTAL ENROLLED CHILDREN:
12
CENSUS:
9
DATE:
04/13/2017
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
09:40 AM
MET WITH:
Bernardita and Domingo Lopez
TIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Paul Petersen met with licensees Bernardita and Domingo Lopez for an unannounced case management visit. There were nine preschool age children present during this visit. LPA discussed the current status of the background clearance process for an individual seeking to be associated to this facility. LPA received copies of the original livescan forms for this individual in order to submit to CBCB air batch unit. Licensees also provided proof of immunizations for all care givers at this facility.
There were no deficiencies cited during this visit. An exit interview was conducted and a copy of the appeals rights was provided. A notice of site visit was issued and is to remain posted for 30 days from this date. A copy of this report was provided and is to remain in the facility records for three years.
SUPERVISORS NAME
:
Anika Evans
LICENSING EVALUATOR NAME
:
Paul Peterson
LICENSING EVALUATOR SIGNATURE
:
DATE:
04/13/2017
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/13/2017
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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