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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201157
Report Date: 06/27/2022
Date Signed: 06/27/2022 10:36:20 AM

Document Has Been Signed on 06/27/2022 10:36 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:
06/27/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Program Director, Gabriel MendozaTIME COMPLETED:
10:45 AM
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On 06/27/2022 at 09:40 AM, Licensing Program Analyst (LPA) L. Holmes arrived announced to conduct a continuation to a Pre-licensing Inspection from 05/26/2022. 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, and office. 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.

CORRECTIONS OBSERVED:
-Screening station has thermometer, sanitizer, masks, gloves, COVID-19 signage, sign-in logs and PPE surplus for staff and clients with an isolation cart.
-Bathrooms are equipped with soap, paper towels, covered garbage cans and 20 second handwashing signs. -Complete first-aid kit
-3 Fire extinguishers; fire extinguishers were last serviced on 06/06/2022.
-Component III completed.
Pre-Licensing is complete with corrections resolved.

LPA observed that facility is 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 to Program Director, Gabriel Mendoza.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2022
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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