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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011441026
Report Date: 04/18/2024
Date Signed: 04/18/2024 02:55:45 PM

Document Has Been Signed on 04/18/2024 02:55 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:
04/18/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:50 PM
MET WITH:Anita TamposTIME VISIT/
INSPECTION COMPLETED:
03:10 PM
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On this day at around 1:50 PM, LPA Luisa Fontanilla arrived unannounced to conduct case management visit as follow up on the informal meeting conducted on 2/13/2024. LPA met with staff Anita Tampos and explained the purpose of the visit. The Administrator was unable to come to the facility but authorized staff to sign the report.

During visit, LPA inspected both perishable and non perishable food supplies. LPA observed sufficient supplies of foods. Clients were served with snacks. LPA inspected the refrigerator and observed rotten carrots, greens and ground beef not in good quality.

Technical assistance was provided to staff to maintain good quality of foods stored in the refrigerator.

Exit interview was conducted with Tampos.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2024
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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