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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010213589
Report Date: 02/13/2019
Date Signed: 03/17/2022 01:44:08 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 & DOMINGOFACILITY NUMBER:
010213589
ADMINISTRATOR:LOPEZ, BERNARDITAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 888-9853
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY: 12TOTAL ENROLLED CHILDREN: 12CENSUS: 8DATE:
02/13/2019
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:LOPEZ, BERNARDITA & DOMINGO, LICENSEESTIME COMPLETED:
01:15 PM
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LPA Redmond conducted a Plan of Correction (POC) visit on this date. LPA met with both Licensees and performed a physical inspection of the facility to verify the POC's were cleared and the facility remained in compliance following LPA's 01/30/2019 Annual/Random inspection visit. Today, LPA verified the following POC's were cleared:

Type A's POCs :

Per Licensee, Type A POC's were faxed to LPA on 02/07/2019 as required. However, LPA had not received the POC's. Licensee was able to produce facsimile transmission reports which, verity POC's were faxed. LPA cleared POC's during today's visit:

102417 (g)(4) x 2
102417 (g)(3)


Type B POCs:

102416.1(a)(b)
1597.622 (a)(1)
102418(6)

NOTE: 102416(c) CPR/Pediatric First Aid due not due until 02/27/2019. Not cleared today.

LPA discussed this report with Licensee, D. Lopez. A copy of POC letters were issued.
SUPERVISORS NAME: Antranette Robinson
LICENSING EVALUATOR NAME: Geneen Redmond
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2019
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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