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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011441026
Report Date: 03/22/2024
Date Signed: 03/22/2024 10:57:09 AM

Document Has Been Signed on 03/22/2024 10:57 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
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: 3DATE:
03/22/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Menchie MatalangTIME COMPLETED:
11:10 AM
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On this day at around 9:55 am, LPA Luisa Fontanilla arrived unannounced to conduct a case management visit as follow up on the informal meeting conducted on 2/13/2024. LPA met with staff Menchie Matalang and explained the purpose of the visit. The Administrator was informed over the telephone but is unable to come. The Administrator authorized Matalang to sign the report.

During the visit, LPA observed 3 clients at the facility. Matalang states one client is in the day program. LPA observed there is sufficient supply of perishable and non perishable foods. Staff was observed cooking spaghetti during the visit. She states it will be served for dinner. And for lunch, tuna sandwich and salad will be served to the clients.

Upon entry to the facility, LPA observed strong food smell. LPA advised staff to make sure that the vent is on when cooking.

A copy of this report was provided to Matalang.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2024
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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