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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200891
Report Date: 12/10/2021
Date Signed: 12/13/2021 11:28:31 AM

Document Has Been Signed on 12/13/2021 11:28 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:
12/10/2021
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Yuka Ono, AdministratorTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Tobola arrived unannounced to conduct a Required - 1 Year inspection and contacted Administrator, Yuka Ono (YO). The annual inspection is focused on the Infection Control procedures and practices of this Adult Residential Facility. There are currently no clients in care.

LPA attempted to conduct a facility inspection but was unsuccessful due to Administrator availability from staff shortages from partnered facilities that YO administrates. LPA Tobola contacted Oakland Regional Office and was informed that an on-site inspection will be reschedule and handled by an LPA associated with the Oakland Regional Office at a later date.

No deficiencies cited during today's visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 12/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2021
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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