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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200982
Report Date: 09/23/2021
Date Signed: 09/23/2021 05:19:36 PM

Document Has Been Signed on 09/23/2021 05:19 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 HOUSE 1FACILITY NUMBER:
019200982
ADMINISTRATOR:ONO, YUKAFACILITY TYPE:
735
ADDRESS:22857 ALICE STREETTELEPHONE:
(510) 677-6889
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 6CENSUS: 6DATE:
09/23/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Lilibeth 'Beth' Toco/House ManagerTIME COMPLETED:
05:25 PM
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct health and safety inspection as a result of the Department receiving a complaint (Control # 15-AS-20210921131741). LPA met with Lilibeth 'Beth' Toco, house manager. LPA called and spoke with Yuka Ono, administrator, over the phone and informed her of the purpose of LPA's visit. Ono stated she can not come to the facility and authorized Toco to be with LPA during inspection, and sign and receive this report.

LPA inspected the living room, dining area, kitchen, clients' bedrooms, bathroom, side yard and backyard.

LPA discussed with Toco the posting of updated visitor's poster and PPE supplies.

No deficiency cited on this day.

Exit interview conducted and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 09/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2021
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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