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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013423039
Report Date: 12/10/2021
Date Signed: 03/09/2022 10:56:54 AM


Document Has Been Signed on 03/09/2022 10:56 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 03/08/2022 03:38 PM

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

NARRATIVE
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---------------------------Created in error, no visit completed--------------------------------------.
SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Diana CamposTELEPHONE: (510) 873-6322
LICENSING EVALUATOR SIGNATURE:
DATE: 12/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/10/2021
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 Has Been Signed on 03/09/2022 10:58 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 03/08/2022 03:52 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: YMCA EASTLAKE CENTER
FACILITY NUMBER: 013423039

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/10/2021
Section Cited

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CREATED IN ERROR-NO DEFICIENCY CITED/ NO VISIT COMPLETED
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N/A
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N/A

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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: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Diana CamposTELEPHONE: (510) 873-6322
LICENSING EVALUATOR SIGNATURE:
DATE: 12/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/10/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2