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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
073407702
Report Date:
04/20/2022
Date Signed:
04/20/2022 03:33:14 PM
Document Has Been Signed on
04/20/2022 03:33 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, SUITE 1102
OAKLAND
,
CA
94612
FACILITY NAME:
PACHECO, VALERIA
FACILITY NUMBER:
073407702
ADMINISTRATOR:
PACHECO, VALERIA
FACILITY TYPE:
810
ADDRESS:
TELEPHONE:
(510) 504-2114
CITY:
SAN PABLO
STATE:
CA
ZIP CODE:
94806
CAPACITY:
14
CENSUS:
12
DATE:
04/20/2022
TYPE OF VISIT:
POC
UNANNOUNCED
TIME BEGAN:
02:20 PM
MET WITH:
VALERIA PACHECO
TIME COMPLETED:
04:00 PM
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Licensing Program Analysts (LPAs) Melissa Domantay and Nyeesha Blount arrived to the facility unannounced at 2:20PM to conduct a Plan of Correction (POC) visit. Present at the time of LPA's arrival were 10 children in care consisting of 3 infants and 9 preschoolers.
The following corrections have been made:
1) 102370(d)(1) Staff is not present at facility.
There are no deficiencies being cited today. Copy of cleared POC letter provided.
An exit interview was conducted. This report must be available for review for 3 years. A notice of site visit was provided to Licensee. Notice of site visit must remain posted for 30 days.
SUPERVISOR'S NAME:
Mayla Mendoza
TELEPHONE:
(510) 292-9724
LICENSING EVALUATOR NAME:
Melissa Domantay
TELEPHONE:
510-725-7021
LICENSING EVALUATOR SIGNATURE:
DATE:
04/20/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/20/2022
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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