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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013418948
Report Date: 09/09/2022
Date Signed: 09/09/2022 03:05:07 PM


Document Has Been Signed on 09/09/2022 03:05 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:SCOTT, VICKTORIYAFACILITY NUMBER:
013418948
ADMINISTRATOR:SCOTT, VICKTORIYAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 287-6873
CITY:BERKELEYSTATE: CAZIP CODE:
94702
CAPACITY:14CENSUS: DATE:
09/09/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Vicktoriya ScottTIME COMPLETED:
03:15 PM
NARRATIVE
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On September 9, 2022 at 1:35pm Licensing Program Analyst (LPA) Indira Loza arrived at the facility unannounced to conduct a complaint investigation. LPA was granted entry to the home and observed 4 children in care during nap time. LPA and Licensee were on the outside patio discussing the nature of the complaint, when the Licensee ordered the LPA to leave and grabbed LPA's belongings and put them on the driveway. Licensee refused to provide children's roster and allow access back into the facility.

A type citation is being issued and a $500 civil penalty.
Deficiency was cited for failing to give the LPA access to the facility. See 809-D for the deficiency 102391(c).

Report and appeal rights provided.
SUPERVISOR'S NAME: Mayla MendozaTELEPHONE: (510) 292-9724
LICENSING EVALUATOR NAME: Indira LozaTELEPHONE: 510-368-3672
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document is an Amendment of Original Document on 09/09/2022 03:13 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612


FACILITY NAME: SCOTT, VICKTORIYA
FACILITY NUMBER: 013418948

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/01/0102
Section Cited

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Inspection Authority of the Department: (c) The licensee shall permit the Department to inspect any part of the family child care home in which family child care services are provided or to which children have access.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Mayla MendozaTELEPHONE: (510) 292-9724
LICENSING EVALUATOR NAME: Indira LozaTELEPHONE: 510-368-3672
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2