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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010213589
Report Date: 04/05/2022
Date Signed: 04/05/2022 02:54:40 PM

Document Has Been Signed on 04/05/2022 02:54 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 STE 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: 3DATE:
04/05/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:13 PM
MET WITH:Bernardita LopezTIME COMPLETED:
03:20 PM
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LPA Cortez conducted a case management visit and verified that the fire extinguisher in the kitchen area has been checked and punched out by the fire department. LPA Cortez visually verified it and the fire extingusiher was and inspected and signed off for 2022 by the fire department.


LPA Cortez also consulted the licensee about the modifying the living room, and use it as one of the main rooms instead of using the garage as the main area for activities. It is currently a work in progress for there is still a workout equipment on the side.
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Sidney Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/05/2022
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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