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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 03:29:15 PM

Document Has Been Signed on 05/17/2024 03:29 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:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:15 PM
MET WITH:Menchie MatalangTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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LPA Luisa Fontanilla conducted a case management visit to issue corrected civil penalty related to the annual inspection conducted on 5/3/2024. LPA informed the Administrator about the visit and authorized Matalang to sign the report.

On 5/3/2024, LPA erroneously issued civil penalty in the amount of $1,000 as indicated in Lic421IM. LPA corrected the mistake and issued civil penalty in the amount of $250.00. LPA retrieved Lic 421IM from Matalang.

A copy of the Lic 421FC in the amount of $250.00 and 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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