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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011441026
Report Date: 03/06/2024
Date Signed: 03/06/2024 04:48:42 PM

Document Has Been Signed on 03/06/2024 04:48 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:
03/06/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Imelda De LeonTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Luisa Fontanilla arrive unannounced to conduct a case management visit to follow up on the concerns discussed in the informal meeting. LPA rang the door bell 3x but no one opened the door. LPA called the Administrator and informed her about LPA presence at the facility. Staff opened the door for LPA at around 3:38pm. The Administrator arrived at around 4pm. All 4 clients were observed at the facility during the visit.

During the visit, LPA was informed by the Administrator that the latest mortgage payment made was for the month of January 2024. She states that February and March mortgage payments will be made on March 18, 2024. The Administrator will send LPA proof of payment by March 19, 2024.

There was sufficient supply of perishable and non perishable foods observed.

The Administrator will meet with caregivers to discuss how to improve quality of foods being served to the clients.

A copy of this report was provided to the Administrator
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2024
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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