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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013421292
Report Date: 08/02/2023
Date Signed: 08/02/2023 11:04:42 AM

Document Has Been Signed on 08/02/2023 11:04 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:RAYMOND, DOROTHEAFACILITY NUMBER:
013421292
ADMINISTRATOR:RAYMOND, DOROTHEAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 938-6666
CITY:BERKELEYSTATE: CAZIP CODE:
94706
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 9DATE:
08/02/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:39 AM
MET WITH:Kristen GarciaTIME COMPLETED:
11:09 AM
NARRATIVE
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On August 2, 2023 at 9:39am Licensing Program Analyst (LPA) Indira Loza met with Assistants K.Garcia and R.Gravessmith. LPA conducted a tour of the facility for a Health and Safety check.

LPA issued a citation on June 7, 2023 for 3 of 5 staff not having a Mandated Reporter Certificate. As of today the Licensee has not corrected the deficiency and will be cited again for failure to have a current mandated Reporter Certificate.

See LIC 809-D for one type B deficiency and Civil Penalty.

Report and Appeal Rights provided to Assistant Kristen Garcia.
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Indira Loza
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 08/02/2023 11:04 AM - It Cannot Be Edited


Created By: Indira Loza On 08/02/2023 at 09:59 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: RAYMOND, DOROTHEA
FACILITY NUMBER: 013421292

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/01/2023
Section Cited
HSC
1596.8662(b)(1)

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On or before March 30, 2018, a person who...is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training...and shall complete renewal mandated reporter training every two years following the date on which
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Licensee shall submit a current Mandated Reporter Certificate.
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he or she completed the initial mandated reporter training.This requirement is not met as evidenced by: Based on interview and record review the Licensee does not have a Mandated Reporter certificate, which poses a potential risk to the health and safety of children in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Mayla Mendoza
LICENSING EVALUATOR NAME:Indira Loza
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2023


LIC809 (FAS) - (06/04)
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