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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 070203461
Report Date: 11/03/2021
Date Signed: 11/03/2021 02:50:33 PM

Document Has Been Signed on 11/03/2021 02:50 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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:SMITH, HENRIETTAFACILITY NUMBER:
070203461
ADMINISTRATOR:SMITH, HENRIETTAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 235-3631
CITY:RICHMONDSTATE: CAZIP CODE:
94804
CAPACITY: 12TOTAL ENROLLED CHILDREN: 12CENSUS: 5DATE:
11/03/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:12 PM
MET WITH:Henrietta SmithTIME COMPLETED:
03:05 PM
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Licensing Program Analyst Caroline Colson met with Henrietta Smith for an unannounced Plan of Correction Inspection. There are five (5) preschool children present. All deficiencies have been cleared from the Required Annual Inspection conducted on October 20, 2021.

An exit interview was conducted. Appeal rights were discussed. This report must be available for public review for 3 years.
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Caroline Colson
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2021
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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