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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010211909
Report Date: 08/30/2023
Date Signed: 08/30/2023 04:53:36 PM


Document Has Been Signed on 08/30/2023 04:53 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:BAHIA SCHOOL AGE PROGRAMFACILITY NUMBER:
010211909
ADMINISTRATOR:LEVYA-CUTLER,B.&CUEVA, M.FACILITY TYPE:
840
ADDRESS:1718 - 8TH STREETTELEPHONE:
(510) 524-7300
CITY:BERKELEYSTATE: CAZIP CODE:
94710
CAPACITY:65CENSUS: 14DATE:
08/30/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:43 PM
MET WITH:Yanci LuceroTIME COMPLETED:
05:03 PM
NARRATIVE
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On August 30, 2023 at 1:43pm Licensing Program Analyst (LPA) Indira Loza met with Site Supervisor Yanci Lucero. Present for the inspection were 14 school-age children. LPA conducted a tour of the facility for a Health and Safety check.

Based on multiple interviews conducted, it has been determined that a child ran away from the facility on more than one occasion and was not reported to CCL.

See LIC 809-D for one Type B deficiency.

An exit interview was conducted with Site Supervisor Yanci Lucero.
Report and Appeal Rights provided.
Notice of Site Visit must remain posted for 30 days.
SUPERVISOR'S NAME: Mayla MendozaTELEPHONE: (510) 292-9724
LICENSING EVALUATOR NAME: Indira LozaTELEPHONE: 510-368-3672
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2023
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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Document Has Been Signed on 08/30/2023 04:53 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: BAHIA SCHOOL AGE PROGRAM
FACILITY NUMBER: 010211909

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/08/2023
Section Cited
CCR
101212(d)(1)(C)

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(d) Upon the occurrence... a report shall be made... within the Department's next working day and during its normal business hours. (1) Events reported shall include the following:(C)Any unusual incident or child absence that threatens the physical or emotional health or safety of any child. This requirement was not
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The Director shall hold an all staff meeting reviewing what events have to be reported, and how to report Unusual incidents to CCL.
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met as evidenced by: Based on interviews it was determined that a child ran away multiple times on undisclosed dates and the incidents were not reported to CCL which poses a potential Health, Safety, and Personal Rights 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: Indira LozaTELEPHONE: 510-368-3672
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2023
LIC809 (FAS) - (06/04)
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