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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013415181
Report Date: 01/30/2020
Date Signed: 01/30/2020 10:45:57 AM

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:OUSD - MARTIN LUTHER KING CDCFACILITY NUMBER:
013415181
ADMINISTRATOR:SLOCUM AM/SLOCUM PMFACILITY TYPE:
850
ADDRESS:960-A TENTH STREETTELEPHONE:
(510) 879-0822
CITY:OAKLANDSTATE: CAZIP CODE:
94607
CAPACITY:75CENSUS: 15DATE:
01/30/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Maria ArciniegaTIME COMPLETED:
10:55 AM
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LPA Lisa Dyer met with assistant Maria Arciniega for a Case Management Inspection to amend the POC report cited at the previous inspection. Also present is substitute teacher Ida Gant and 15 preschool aged children.

As a result of this inspection, there are no deficiencies cited.

Notice of site visit was must be posted for 30 days. An exit interview was conducted. This report must be available for public review for 3 years.



SUPERVISOR'S NAME: Ann RobinsonTELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Phyllis DyerTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2020
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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