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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013419824
Report Date: 03/27/2024
Date Signed: 03/27/2024 12:15:44 PM


Document Has Been Signed on 03/27/2024 12:15 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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612



FACILITY NAME:CHAVEZ, MARJORIEFACILITY NUMBER:
013419824
ADMINISTRATOR:CHAVEZ, MARJORIEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 393-5063
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:14CENSUS: 3DATE:
03/27/2024
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Marjorie ChavezTIME COMPLETED:
12:30 PM
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On March 27, 2024 at 11:30 AM, Licensing Program Analyst (LPA) Elimika Woods met with licensee Marjorie Chavez for an unannounced case management inspection for the purpose of adding an off limits area to on-limits. Present for today's inspection were three preschool age children. The hours of operation are Monday through Friday from 5:30 AM - 6:30 PM.

The facility has requested to change the off-limits area of the front middle bedroom to on-limits space for children in care. The room will be utilized for play and learning and has plenty of toys and games for children.

On-limit-areas are the: Bedroom (1) in the front middle area of home, living room, dining room, kitchen, bathroom next to hall, and backyard.

Off-limit-areas are the: Left side of the backyard which is inaccessible by a gate/barrier, bedroom (2) bedroom (3), playroom and second garage.

LPA reminded the licensee that all further additions or changes to the facility, including outdoor play structures, must be approved by the Licensing Department before use by children.

There are no deficiencies cited today. This report shall remain on file for 3 years. Exit interview conducted with Marjorie Chavez.
SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Elimika WoodsTELEPHONE: (510) 622-2550
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2024
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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