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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011441026
Report Date: 02/22/2024
Date Signed: 02/22/2024 04:52:45 PM

Document Has Been Signed on 02/22/2024 04:52 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:DELEON, IMELDA F.FACILITY TYPE:
735
ADDRESS:6185 BROADWAY AVENUETELEPHONE:
(510) 894-3311
CITY:NEWARKSTATE: CAZIP CODE:
94560
CAPACITY: 6CENSUS: 4DATE:
02/22/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Imelda De Leon, AdministratorTIME COMPLETED:
05:00 PM
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At around 2:50pm, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct a case management visit to follow up concerns discussed during the facility's informal meeting. LPA was met by staff Anita Tampos. Administrator Imelda De Leon was notified about LPA presence at the facility. The Administrator arrived at approximately

During the visit, LPA inspected both perishable and non perishable foods. LPA reviewed menu posted on the refrigerator and interviewed Tampos. LPA was informed that Client 1 (C1) is on pureed diet. LPA discussed with Imelda and Tampos alternative options for C1's diet. LPA observed there was sufficient supply of perishable and non perishable foods of different variety. A pack of chicken with "sell by 11/28/2023" date was discarded. Some apples that were observed not in good quality were also discarded during the visit.

LPA advised the Administrator to have the kitchen including the refrigerator cleaned.

There is no deficiency noted for today's visit.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2024
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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