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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200471
Report Date: 11/22/2022
Date Signed: 11/22/2022 03:04:55 PM

Document Has Been Signed on 11/22/2022 03:04 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:HEIWA GROWTH HOUSEFACILITY NUMBER:
019200471
ADMINISTRATOR:YUKA ONOFACILITY TYPE:
735
ADDRESS:2686 HILLCREST AVENUETELEPHONE:
(510) 677-6889
CITY:HAYWARDSTATE: CAZIP CODE:
94542
CAPACITY: 6CENSUS: 5DATE:
11/22/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Marilou Moise, CaregiverTIME COMPLETED:
03:10 PM
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On 11/22/2022, at 2:15PM, Licensing Program Analysts (LPAs) L. Hall and L. Holmes arrived unannounced to conduct proof of correction (POC) visit. LPA met with Marilou Moise, Caregiver and explained the purpose of the visit. LPA spoke with Administrator, Lilabeth Toco via telephone and was given approval for Caregiver to sign documents.

LPAs toured facility with Caregiver including but not limited to common areas and back yard. LPA received email containing pictures of back yard and thermostat. LPAs confirmed that heater was working prior to clearing POC. LPA observed facility have vents in the floor. LPA step on vent and that vent was warm.



No deficiencies cited during visit.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2022
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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