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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011441026
Report Date: 02/17/2024
Date Signed: 02/17/2024 10:51:16 AM

Document Has Been Signed on 02/17/2024 10:51 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:BROADWAY HOMEFACILITY NUMBER:
011441026
ADMINISTRATOR:DELEON, IMELDA F.FACILITY TYPE:
735
ADDRESS:6185 BROADWAY AVENUETELEPHONE:
(510) 894-3311
CITY:NEWARKSTATE: CAZIP CODE:
94560
CAPACITY: 6CENSUS: 4DATE:
02/17/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Imelda de Leon/Licensee/AdministratorTIME COMPLETED:
11:15 AM
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On 02/17/2024 at 9:30 AM, Licensing Program Analyst (LPA) Lori Alexander arrived unannounced to conduct Plan of Correction (POC). LPA met with Caregiver, Menchie Matalang, and explained the purpose of the visit. LPA phoned Licensee, Imelda de Leon to inform arrival. Imelda de Leon arrived at the facility around 9:50AM.

On 02/14/2024, LPA L. Alexander conducted an Case Management Health & Safety Check and issued Type B citations for the following deficiencies with POCs to be submitted by 02/16/2024. Licensee, Imelda de Leon stated that she tried submitting copies and pictures of the receipts and food purchases but said that she was unable to submit the proof.

Deficiencies cited 02/14/2024:

CCR 85076(d)(1)
CCR 87555(b)(8)
CCR 87465(a)(8)

No deficiencies cited during visit. Deficiencies cleared. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE: DATE: 02/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/17/2024
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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