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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201202
Report Date: 11/04/2022
Date Signed: 11/04/2022 04:54:38 PM

Document Has Been Signed on 11/04/2022 04:54 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:BELLA VISTAFACILITY NUMBER:
019201202
ADMINISTRATOR:BAUTISTA, HAIDIEFACILITY TYPE:
740
ADDRESS:1641-1659 D STREETTELEPHONE:
(510) 397-0751
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 42CENSUS: 15DATE:
11/04/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:10 PM
MET WITH:Haidie Bautista/Applicant-administratorTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Delmundo conducted Component III Training via Teams Meeting. Component III was attended by Haidie Bautista, applicant-administrator.

LPA Delmundo presented the training via Power Point presentation and had a discussion with Haidie Bautista.

Exit interview conducted and copy of this report provided at the conclusion of the training.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2022
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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