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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200891
Report Date: 11/09/2021
Date Signed: 11/10/2021 08:49:55 AM

Document Has Been Signed on 11/10/2021 08:49 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,
, CA
FACILITY NAME:HEIWA GROWTH HOUSE 2FACILITY NUMBER:
019200891
ADMINISTRATOR:ONO, YUKAFACILITY TYPE:
735
ADDRESS:24527 MARIE DRTELEPHONE:
(510) 677-6889
CITY:HAYWARDSTATE: CAZIP CODE:
94542
CAPACITY: 6CENSUS: 0DATE:
11/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Yuka Ono, AdministratorTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Tobola arrived unannounced attempting to conduct a Required - 1 Year inspection and spoke with Administrator, Yuka Ono (YO) over the phone. The annual inspection is focused on the Infection Control procedures and practices of this Adult Residential Facility.

LPA was informed by Administrator that the facility currently does not have any clients in care and is awaiting vendorization from East Bay Regional Center with expected admission beginning in 2022. Administrator stated that no staff were available to conduct a tour of the facility due to medical emergencies and designated responsible parties assisting clients with Day Program appointments and pickup for partnered facilities under same licensee.

LPA observed the front of the facility and confirmed no staff or clients were present on this day at the time of visit.

No citations cited during this inspection
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2021
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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