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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200891
Report Date: 01/18/2024
Date Signed: 01/18/2024 04:13:11 PM

Document Has Been Signed on 01/18/2024 04:13 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
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:
01/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Manager, Anthony MontgomeryTIME COMPLETED:
04:25 PM
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On 1/10/2024 at 7:00 AM LPA A Gomez attempted to conduct an unannounced annual random visit. LPA arrived at the facility and found no one present. LPA contacted the Licensee via telephone to obtain hours of operation, and found that facility is not yet vendorized so there are no staff or clients.

Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct a 1-Year Annual Inspection on this date starting at 3:00pm. Upon arrival, LPA met with Manager, Anthony Montgomery. The facility's fire clearance is approved for all residents may be ambulatory. Facility is currently not in operation and has no clients or staff.

LPA toured facility with manager including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. All fixtures in facility are adequate and prepared for the arrival of clients/residents.

LPA observed carbon monoxide and smoke detectors. First aid kit was observed to be complete.

Administrator to submit the following by February 01, 2024:
  • LIC500 Personnel Report



No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE: DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/18/2024
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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