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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073406662
Report Date: 10/29/2020
Date Signed: 10/29/2020 03:15:12 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
FACILITY NAME:YMCA OF THE EAST BAY - WOODSIDEFACILITY NUMBER:
073406662
ADMINISTRATOR:LUPE LOPEZFACILITY TYPE:
840
ADDRESS:761 SAN SIMEON DRTELEPHONE:
(925) 602-0114
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY:102CENSUS: 15DATE:
10/29/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Lupe Lopez/Andrea GarciaTIME COMPLETED:
09:45 AM
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On 10/29/20 at 9:30 AM Licensing Program Analyst (LPA) Monica Mathur conducted an unannounced Case Management inspection at YMCA of the East Bay - Woodside Center and spoke with Site Director, Lupe Lopez and Assistant Director, Andrea Garcia. Due to COVID restrictions, this inspection was done through phone call.

LPA followed up on an incident that was self reported by the Center regarding a child who was injured during outdoor play. LPA interviewed Assistant Director and obtained relevant documents.

No deficiencies were issued today. Exit Interview was conducted, where this report was reviewed and discussed with the Director. Report will be sent to Director to obtain her signatures and returned by end of 10/30/20.
SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 725-5998
LICENSING EVALUATOR NAME: Monica MathurTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2020
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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