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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010210187
Report Date: 11/30/2023
Date Signed: 11/30/2023 05:25:24 PM


Document Has Been Signed on 11/30/2023 05:25 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:ALA COSTA CTR. FOR THE DEVELOPMENTALLY DISABLEDFACILITY NUMBER:
010210187
ADMINISTRATOR:PEREIRA, MICHAEL A.FACILITY TYPE:
840
ADDRESS:1300 ROSE STREETTELEPHONE:
(510) 527-2550
CITY:BERKELEYSTATE: CAZIP CODE:
94702
CAPACITY:58CENSUS: 11DATE:
11/30/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Michael A. PereiraTIME COMPLETED:
04:08 PM
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On 11/30/2023 Licensing Program Analyst (LPA) Diana Campos, arrived at the facility for an unannounced case management inspection following a self reported incident. LPA met with Executive Director Michael Pereira. Present during this visit were 7 staff and 11 school age students.

LPA toured the facility with the director, Michael Pereira. Observations and interviews were conducted. Copies of the Facility Roster, personnel report, and other relevant documents were obtained.

As a result of this visit, no deficiencies were cited. This report will remain on file for 3 years.

A Notice of Site Visit was provided, and must remain posted for 30 days.
Exit interview conducted and report reviewed with Executive Director Michael Pereira.
SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Diana CamposTELEPHONE: (510) 873-6322
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023
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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