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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201157
Report Date: 05/26/2022
Date Signed: 05/27/2022 08:25:36 AM

Document Has Been Signed on 05/27/2022 08:25 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:MITC EAST BAYFACILITY NUMBER:
019201157
ADMINISTRATOR:MENDOZA, GABRIELFACILITY TYPE:
775
ADDRESS:2192 E 14TH STTELEPHONE:
(408) 427-7119
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY: 70CENSUS: 0DATE:
05/26/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Program Director, Gabriel MendozaTIME COMPLETED:
02:30 PM
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On 5/26/2022 at 1:10 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct a Pre-licensing Inspection. Upon arrival, LPA was greeted by Gabriel Mendoza. Program Director, (PD). The facility is approved for a capacity of 70.

LPA toured facility with PD including, but not limited to the common areas, activity/cohort rooms, bathrooms, conference room, office, front area and backyard. The client’s activity rooms were equipped with the proper furniture and enough space for everyone to social distance. Lighting is sufficient throughout the facility. The room temperature was maintained at 70 degrees F and hot water temperature was measured at 116.2 degrees F. Smoke and carbon monoxide detectors were operational with 2 fire pull-down alerts.
CORRECTIONS:
-Screening station with thermometer, sanitizer, masks, gloves, COVID-19 signage, sign-in logs and PPE surplus for staff and clients with an isolation cart.
-Bathrooms to be equipped with soap, paper towels, covered garbage cans and 20 second handwashing signs.
-Complete first-aid kit
-4 Fire extinguishers; fire extinguishers were last serviced on 11/11/2019.
-Component III will be reviewed and completed with PD once deficiencies are cleared.
Pre-Licensing is incomplete with deficiencies to be resolved by 06/08/2022. A follow-up Pre-licensure LIC809 will be generated upon resolution of deficiencies.

LPA observed that facility is not ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAU. Additional requirements may still be required.
Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/26/2022
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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