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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013422571
Report Date: 04/11/2022
Date Signed: 04/11/2022 03:00:27 PM


Document Has Been Signed on 04/11/2022 03:00 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 STE 1102
OAKLAND, CA 94612



FACILITY NAME:LOW, JACQUELINEFACILITY NUMBER:
013422571
ADMINISTRATOR:LOW, JACQULINEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 875-5649
CITY:SAN LEANDROSTATE: CAZIP CODE:
94578
CAPACITY:14CENSUS: 6DATE:
04/11/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Licensee, Jacqueline LowTIME COMPLETED:
03:10 PM
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Licensing Program Analyst Jyoti Saini met with licensee Jacqueline Low for an unannounced POC. LPA disclosed the purpose of the inspection and was granted entry into the facility by the licensee. Present during this inspection was Licensee and helper supervising 4 infants and 2 preschoolers. Licensee is within the capacity ratio during today's inspection. LPA Saini cleared deficiency cited on 03/24/2022 for the facility being over capacity.

There are no deficiencies cited today. Copy of Cleared POC letters were provided. An exit interview was conducted with licensee, Jacquline Low. A notice of site visit was posted. Notice of site visit must remain posted for 30 days.
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Jyoti SainiTELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2022
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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