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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011441026
Report Date: 05/17/2024
Date Signed: 05/17/2024 03:27:48 PM

Document Has Been Signed on 05/17/2024 03:27 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, STE. 310
OAKLAND, CA 94612
FACILITY NAME:BROADWAY HOMEFACILITY NUMBER:
011441026
ADMINISTRATOR/
DIRECTOR:		DELEON, IMELDA F.FACILITY TYPE:
735
ADDRESS:6185 BROADWAY AVENUETELEPHONE:
(510) 894-3311
CITY:NEWARKSTATE: CAZIP CODE:
94560
CAPACITY: 6CENSUS: 4DATE:
05/17/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:20 PM
MET WITH:Menchie MatalangTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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ON this day at around 2:20pm, LPA Luisa Fontanilla arrived unannounced to conduct a Plan of Correction (POC) visit and met with staff Menchie Matalang. LPA explained to Matalang the purpose of visit. The Administrator was informed over the phone about the visit and she authorized staff to sign the report.

During the visit, LPA observed deficiencies cited and have POC date of 5/6/2024 have been corrected.

While on the telephone with the Administrator, LPA discussed the citation regarding day staff-client ratio. LPA reminded the Administrator to submit the plan of correction by today..

A copy of this report was provided to Matalang.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2024
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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