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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010206120
Report Date: 07/20/2022
Date Signed: 07/20/2022 03:39:50 PM


Document Has Been Signed on 07/20/2022 03:39 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 - WESTFACILITY NUMBER:
010206120
ADMINISTRATOR:MURRAY, CHERYLFACILITY TYPE:
850
ADDRESS:2009 10TH STREETTELEPHONE:
(510) 848-9092
CITY:BERKELEYSTATE: CAZIP CODE:
94710
CAPACITY:70CENSUS: 16DATE:
07/20/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Cheryl MurrayTIME COMPLETED:
03:40 PM
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On 7//20/22 at 2:50 PM Licensing Program Analyst (LPA) Michelle Sutton met with Director Cheryl Murray to conduct a Case Management inspection at Berkeley YMCA Head Start- West for an Unusual Incident report that was received at the CCLD office on 6/13/22.

During today's inspection LPA spoke with the director and watched video footage of the incident that was reported by the facility.

There were no deficiencies cited during today's visit. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the director Cheryl Murray.


SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Michelle SuttonTELEPHONE: (510) 725-7004
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2022
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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