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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073400419
Report Date: 02/15/2023
Date Signed: 02/15/2023 01:05:02 PM


Document Has Been Signed on 02/15/2023 01:05 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
BAY AREA-CC OAKLAND, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612



FACILITY NAME:WCCUSD - MONTALVIN C/O PRESCHOOL DEPARTMENTFACILITY NUMBER:
073400419
ADMINISTRATOR:ROMERO, VENESSAFACILITY TYPE:
850
ADDRESS:300 CHRISTINE DRIVETELEPHONE:
(510) 231-1405
CITY:SAN PABLOSTATE: CAZIP CODE:
94806
CAPACITY:24CENSUS: 19DATE:
02/15/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:12 AM
MET WITH:Derri PollackTIME COMPLETED:
01:19 PM
NARRATIVE
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On Wednesday, February 15, 2023 at 10:12 AM, Licensing Program Analyst (LPA) Caroline Colson met with Derri Pollack, Lead Teacher, for an unannounced case management inspection. There are 19 children with 3 staff members present. The purpose of the inspection was the result of receiving an unusual incident report. An interview was conducted.

There were no deficiencies cited during this inspection.

An exit interview was conducted. Appeal Rights were given and discussed.
SUPERVISOR'S NAME: Mayla MendozaTELEPHONE: (510) 292-2724
LICENSING EVALUATOR NAME: Caroline ColsonTELEPHONE: (510) 725-7008
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2023
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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