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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013419473
Report Date: 08/11/2021
Date Signed: 08/11/2021 10:55:21 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:CITY OF UNION CITY - HOLLY CENTERFACILITY NUMBER:
013419473
ADMINISTRATOR:VERA, MARISSAFACILITY TYPE:
850
ADDRESS:31600 ALVARADO BLVD.TELEPHONE:
(510) 675-5488
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:19CENSUS: 10DATE:
08/11/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Marissa VeraTIME COMPLETED:
11:05 AM
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On 08/11/2021 at 10:15am, LPA Williams met with Director, Marissa Vera, for the purposes of conducting an unannounced Plan of Correction visit in response to deficiencies cited during site visit conducted on 08/06/2021. Present for today's inspection are Director, fingerprint cleared and associated teacher Rosalie Corsi, and ten preschool-aged children in care.

During site visit conducted on 08/06/2021, a Type A violation was cited in response to staff member Roselle Capili lacking a fingerprint clearance. This deficiency is cleared during today's visit, as Capili has been successfully fingerprint cleared and associated to the facility. Capili was not present during today's inspection and per Director, Capili has not returned to the facility since site visit conducted on 08/06/2021.

See cleared POC letters dated today, 08/11/2021. POC letters were provided to Director during today's visit. No deficiencies were cited. Notice of Site Visit was provided and must be posted for a period of 30 days. Appeal Rights provided to the Director. Exit interview conducted.
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 622-2602
LICENSING EVALUATOR NAME: Jonathan WilliamsTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021
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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