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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200891
Report Date: 11/20/2024
Date Signed: 11/21/2024 11:46:34 AM

Document Has Been Signed on 11/21/2024 11:46 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:HEIWA GROWTH HOUSE 2FACILITY NUMBER:
019200891
ADMINISTRATOR/
DIRECTOR:		ONO, YUKAFACILITY TYPE:
735
ADDRESS:24527 MARIE DRTELEPHONE:
(510) 677-6889
CITY:HAYWARDSTATE: CAZIP CODE:
94542
CAPACITY: 6CENSUS: 0DATE:
11/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:55 AM
MET WITH:Lilibeth Toco, House ManagerTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 11/20/2024 at 11:30 AM LPA K. Nguyen attempted to conduct an unannounced 1 year required annual inspection. LPA arrived at the facility and found no one present. LPA contacted the Administrator via telephone to obtain hours of operation, and found that facility is not yet vendorized so there are no staff or clients.

LPA will return at a later time to conduct the required 1-year annual.

Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct a 1-Year Annual Inspection on this date starting at 10:55am. Upon arrival, LPA met with House Manager, Lilibeth Toco. 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 December 05, 2024:
ยท LIC500 Personnel Report


No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2024
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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