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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073406612
Report Date: 12/22/2022
Date Signed: 12/22/2022 11:40:21 AM


Document Has Been Signed on 12/22/2022 11:40 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:BLACKLOCK, ATCHAFACILITY NUMBER:
073406612
ADMINISTRATOR:BLACKLOCK, ATCHAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 778-9172
CITY:EL CERRITOSTATE: CAZIP CODE:
94530
CAPACITY:14CENSUS: 12DATE:
12/22/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:BLACKLOCK,ATCHATIME COMPLETED:
12:00 PM
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On December 22, 2022 at 8:30AM Licensing Program Analyst Nyeesha Blount met with licensee Blacklock, Atcha to conduct an unannounced case management visit to clear deficiencies cited on 12/09/22, POC visit. The following deficiencies have been cleared:

1) 102416.5(b)(3)- Licensee is now within capacity of her license.

During a previous inspection, the following was cited:

1. No disaster drills documented.
2. No children or staff records for review.
3. No roster completed.
4. Mandated Reporter's Certificate & CPR/First Aid Expired.
5. Carbon Monoxide Detector not working.
6. Preventative health & safety course with nutrition & lead poisoning certificate.

The deficiencies listed above have been corrected.

See cleared POC dated December 22, 2022
Today no deficiencies were cited. An exit interview was conducted with Blacklock, Atcha

Appeal rights were discussed and given. Notice of site visit was also given to post for 30 days.
SUPERVISOR'S NAME: Mayla MendozaTELEPHONE: (510) 292-9724
LICENSING EVALUATOR NAME: Nyeesha BlountTELEPHONE: (510) 566-2319
LICENSING EVALUATOR SIGNATURE:
DATE: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2022
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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