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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
013421405
Report Date:
07/14/2023
Date Signed:
07/14/2023 11:09:30 AM
Document Has Been Signed on
07/14/2023 11:09 AM
- 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:
DUCKS NEST - 41ST STREET
FACILITY NUMBER:
013421405
ADMINISTRATOR:
MONIKA VON GIERKE-STOLTZ
FACILITY TYPE:
850
ADDRESS:
250 - 41ST ST
TELEPHONE:
(510) 654-3825
CITY:
OAKLAND
STATE:
CA
ZIP CODE:
94611
CAPACITY:
80
CENSUS:
54
DATE:
07/14/2023
TYPE OF VISIT:
Case Management - Incident
UNANNOUNCED
TIME BEGAN:
08:30 AM
MET WITH:
Fernndo Souza
TIME COMPLETED:
11:30 AM
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On 7/14/2023 Licensing Program Analyst (LPA) Diana Campos conducted an unannounced case management inspection to follow up on a self reported incident. LPA met with Assistant Director Fernando Souza. LPA toured the facility with Director Nancy Rodriguez. Ms. There were 16 staff and 53 preschool children present during the inspection.
During the inspection LPA obtained a copy of the facility roster and conducted interviews.
There are no deficiencies cited during today's inspection.
Exit interview and report reviewed with Assistant Director Fernando Souza .
Notice of Site Visit was provided and must be posted for 30 days.
SUPERVISOR'S NAME:
Sherelle Johnson
TELEPHONE:
(510) 622-2592
LICENSING EVALUATOR NAME:
Diana Campos
TELEPHONE:
(510) 873-6322
LICENSING EVALUATOR SIGNATURE:
DATE:
07/14/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/14/2023
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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