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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013416121
Report Date: 03/18/2022
Date Signed: 03/18/2022 10:04:27 AM

Document Has Been Signed on 03/18/2022 10:04 AM - 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:JOHNSON, KEVIN M.FACILITY NUMBER:
013416121
ADMINISTRATOR:JOHNSON, KEVIN M.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 923-0095
CITY:OAKLANDSTATE: CAZIP CODE:
94618
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
03/18/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:34 AM
MET WITH:Kevin Johnson TIME COMPLETED:
10:15 AM
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On 3/18/22 at 9:34AM, Licensing Analyst Program (LPA) Catherine Fernandes arrived unannounced on an annual inspection and met with Licensee Kevin Johnson.

As stated by the Licensee, the day care has not cared for children for the past year and would like to be put on inactive as of today's date. While at the home LPA Fernandes got the licensee's updated contact information and went over the stipend. LPA also reminded the Licensee that any advertising needs to have the license facility number on it and to be sure to complete CPR and mandated reporter training prior to reopening.



Exit interview conducted
Report and Appeal Rights provided

SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Catherine Fernandes
LICENSING EVALUATOR SIGNATURE: DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2022
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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