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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010200607
Report Date: 06/02/2022
Date Signed: 06/02/2022 04:23:30 PM


Document Has Been Signed on 06/02/2022 04:23 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:BERKELEY YMCA HEAD START - SOUTH YMCAFACILITY NUMBER:
010200607
ADMINISTRATOR:CAMERON SCOTTFACILITY TYPE:
850
ADDRESS:2901 CALIFORNIA STREETTELEPHONE:
(510) 848-9092
CITY:BERKELEYSTATE: CAZIP CODE:
94703
CAPACITY:52CENSUS: DATE:
06/02/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:11 PM
MET WITH:Dorian BurnleyTIME COMPLETED:
04:30 PM
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LPA Indira Loza and Regional Manager Diane Perez arrived at the facility at 4:11 pm to deliver a notice of Exclusion letter for staff person Ariel Pringle. The letter was explained to Director Dorian Burnley and appeal rights were provided.

Director is informed that all the parents must be notified of the exclusion of Ariel Pringle by posting the report for 30 days.

SUPERVISOR'S NAME: Mayla MendozaTELEPHONE: (510) 292-9724
LICENSING EVALUATOR NAME: Indira LozaTELEPHONE: 510-368-3672
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2022
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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