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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010200607
Report Date: 05/11/2023
Date Signed: 05/11/2023 02:43:48 PM


Document Has Been Signed on 05/11/2023 02:43 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:DORIAN BURNLEYFACILITY TYPE:
850
ADDRESS:2901 CALIFORNIA STREETTELEPHONE:
(510) 848-9092
CITY:BERKELEYSTATE: CAZIP CODE:
94703
CAPACITY:52CENSUS: 21DATE:
05/11/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:27 PM
MET WITH:Dorian BurnleyTIME COMPLETED:
02:28 PM
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On May 11, 2023 at 2:27pm Licensing Program Analyst (LPA) Indira Loza and Licensing Program Manager (LPM) Mayla Mendoza met with Director Dorian Burnley. There were 21 children and 6 staff present during today's visit.

The purpose of the visit was due to a self reported incident that was sent to the Oakland Regional office. LPA and LPM interviewed Director Burnley regarding the incident that occurred in the facility.

No deficiencies cited during today's visit.

Exit interview conducted.
A copy of the report and appeal rights provided to Director Dorian Burnley.
Notice of Site Visit provided.
SUPERVISOR'S NAME: Mayla MendozaTELEPHONE: (510) 292-9724
LICENSING EVALUATOR NAME: Indira LozaTELEPHONE: 510-368-3672
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2023
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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