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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013423114
Report Date: 01/23/2023
Date Signed: 01/23/2023 12:41:58 PM

Document Has Been Signed on 01/23/2023 12:41 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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:UC BERKELEY-DWIGHT WAY CHILD DEVELOPMENT CENTERFACILITY NUMBER:
013423114
ADMINISTRATOR:ALVARADO, BORISFACILITY TYPE:
850
ADDRESS:2427 DWIGHT WAYTELEPHONE:
(510) 642-0104
CITY:BERKELEYSTATE: CAZIP CODE:
94720
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 17DATE:
01/23/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:13 AM
MET WITH:Boris AlvaradoTIME COMPLETED:
12:45 PM
NARRATIVE
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On January 23, 2023 at 10:13am Licensing Program Analyst (LPA) Indira Loza arrived at the facility to conduct a case management visit as a direct result to an Unusual Incident report received in our office.

Based on record review and interviews conducted, it was determined that a child left the facility unsupervised onto the public sidewalk and returned by two pedestrians. This is a Type A violation of section 101223(a)(2).

The Director must provide a copy of this report to all parents of children currently enrolled, and the parents of newly enrolled children in the next 12 months. In addition, Form LIC 9224 (Acknowledgment of receipt of Licensing Reports) must be signed by each parent and placed in each child's file.

A copy of the LIC 9224 is being provided to the Director during the inspection.

Exit Interview conducted with Director Boris Alvarado.

Appeal Rights and report provided.

SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Indira Loza
LICENSING EVALUATOR SIGNATURE: DATE: 01/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2023
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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Document Has Been Signed on 01/23/2023 12:41 PM - It Cannot Be Edited


Created By: Indira Loza On 01/23/2023 at 12:14 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: UC BERKELEY-DWIGHT WAY CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 013423114

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/24/2023
Section Cited
CCR
101223(a)(2)

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101223 - Personal Rights - (a) The licensee shall ensure that each child is accorded the following personal rights
... (2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
This requirement was not met as evidenced
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Director shall submit a written plan of action indicating how he will ensure there are no future incidents.
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by: a child left the facility unsupervised onto the public sidewalk. This poses an immediate risk to the health and safety of children in care.
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Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violation will result in a $1000 civil penalty.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Mayla Mendoza
LICENSING EVALUATOR NAME:Indira Loza
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2023


LIC809 (FAS) - (06/04)
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