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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 03:34:21 PM


Document Has Been Signed on 04/20/2022 03:34 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, VALERIAFACILITY NUMBER:
073407702
ADMINISTRATOR:PACHECO, VALERIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 504-2114
CITY:SAN PABLOSTATE: CAZIP CODE:
94806
CAPACITY:14CENSUS: 12DATE:
04/20/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:VALERIA PACHECOTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Melissa Domantay and Nyeesha Blount arrived to the facility unannounced to conduct a Case Management and POC visit. Present during today's visit were 12 children (3 infants, 9 preschoolers).

LPAs performed a health & safety check. See 809-D for the TYPE B deficiency that is being cited on today's visit. An exit interview was conducted. The licensee was provided a copy of their appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights.

Upon receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians newly enrolled at the facility during the next 12 months.
SUPERVISOR'S NAME: Mayla MendozaTELEPHONE: (510) 292-9724
LICENSING EVALUATOR NAME: Melissa DomantayTELEPHONE: 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)
Page: 1 of 2


Document Has Been Signed on 04/20/2022 03:34 PM - It Cannot Be Edited

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: PACHECO, VALERIA
FACILITY NUMBER: 073407702

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/20/2022
Section Cited

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This requirement was not met as evidenced by observation. The are 3 infants 9 preschoolers present wirh licensee was present at the time of arrival. This poses a potential health and safety risk to children in care.

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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: Mayla MendozaTELEPHONE: (510) 292-9724
LICENSING EVALUATOR NAME: Melissa DomantayTELEPHONE: 510-725-7021
LICENSING EVALUATOR SIGNATURE:
DATE: 04/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2