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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013416337
Report Date: 01/18/2022
Date Signed: 01/18/2022 09:37:00 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 STE 1102
OAKLAND, CA 94612
FACILITY NAME:PIERCE, FORRESTINEFACILITY NUMBER:
013416337
ADMINISTRATOR:PIERCE, FORRESTINEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 581-1109
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94546
CAPACITY:14CENSUS: 7DATE:
01/18/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Forrestine Pierce- LicenseeTIME COMPLETED:
09:44 AM
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On 1/18/22 at 8:40am, Licensing Program Analyst (LPA) Briana Plumboy met with licensee Forrestine Pierce for an UNANNOUNCED CASE MANAGEMENT INSPECTION. Present for this inspection is licensees fingerprint clear and associated assistant and 7 children in care. LPA B. Plumboy toured the facility and conducted a physical census of the children in care.

Licensee Mrs. Pierce completed and received a new CPR and First Aid certificate which expires 1/15/24.

There are no deficiencies cited. This report shall remain on file for 3 years. A notice of site visit was given and must remain posted for 30 days. Appeal Rights provided. Exit interview conducted.
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Briana PlumboyTELEPHONE: (510) 725-7005
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2022
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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