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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
073405692
Report Date:
11/13/2024
Date Signed:
11/13/2024 04:32:57 PM
Document Has Been Signed on
11/13/2024 04:32 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
OAKLAND CC RO
,
1515 CLAY STREET, SUITE 1102
OAKLAND
,
CA
94612
FACILITY NAME:
SRVSACCA-CREEKSIDE
FACILITY NUMBER:
073405692
ADMINISTRATOR/
DIRECTOR:
SAMS, DANI
FACILITY TYPE:
840
ADDRESS:
6055 MASSARA ST
TELEPHONE:
(925) 743-3170
CITY:
DANVILLE
STATE:
CA
ZIP CODE:
94506
CAPACITY:
188
TOTAL ENROLLED CHILDREN:
188
CENSUS:
48
DATE:
11/13/2024
TYPE OF VISIT:
Case Management - Incident
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
03:15 PM
MET WITH:
Nicole Ward
TIME VISIT/
INSPECTION COMPLETED:
04:40 PM
NARRATIVE
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On 11/13/24 at 3:15 PM Licensing Program Analysts (LPAs) Joe Mary Vargas and Cherie Acosta conducted an unannounced Case management inspection to follow up with the self reported incident. LPAs met with the interim director Nicole Ward.
During the visit LPAs conducted interviews and there is no deficiency cited today.
Exit interview was conducted and report was reviewed with the interim director Nicole Ward.
SUPERVISORS NAME
:
Monica Mathur
LICENSING EVALUATOR NAME
:
Joe Mary Vargas
LICENSING EVALUATOR SIGNATURE
:
DATE:
11/13/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/13/2024
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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